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REGIONAL ONE HEALTH 877 JEFFERSON AVENUE MEMPHIS, TN 38103 Oct. 12, 2016
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy, Ambulance Patient Care Record, medical record review and interview, the facility delayed moving patients from an Emergency Medical Services (EMS) stretcher and EMS oversight of patients to an Emergency Department (ED) bed and ED staff oversight and care, and failed to provide continuing monitoring for 6 of 20 (Patient's #2, 7, 9, 14, 17, and 18) patients reviewed.

The findings included:

1. Review of the facility policy, "Triage Guidelines" revealed, "Triage is an essential function of an emergency department (ED). Triage is the first interaction a patient has in the Emergency Department. The aim is to ensure that patients are treated in order of clinical urgency... The goal of triage is to expedite patients care by prompt and accurate assessment, which prioritizes patient into levels, resulting in appropriate response levels for medical evaluation and treatment...Triage of patients will be performed by a Registered Nurse [RN], who has received specialized training to assess the care required for patients assigned to ESI [Emergency Severity Index] levels 1-5. The triage nurse determines the patient's acuity, assigns a triage level, and designates the appropriate treatment area... Patients categorized as (Level 3) remaining in the waiting room, will be reassessed every two (2) hours or as condition warrants. All changes and reassessments are documented in the patient record..."


2. Review of the hospital EMTALA Policy revealed, "...Purpose: To ensure that all patients presenting to [name of Hospital #1] requesting emergency treatment receive an appropriate MSE [Medical Screening Exam] to determine whether or not an emergency medical condition [EMC] exits...An MSE consists of an assessment and any ancillary test (based on the patient's chief complaint) necessary to determine if an emergency medical condition exists. This may be a brief history and physical or may require complex ancillary studies and procedures (such as lab test, fetal monitoring, EKG, or radiology procedures)...NOTE: When the provider begins the medical screening exam, he/she will indicate the time by activating the screening exam indicator within the Medhost EMR [electronic medical record]. The medical screening examination will be used to determine if an emergency medical condition exits and the process will not be considered complete until final disposition of the patient is performed by the provider which may include but is not limited to admission, transfer or discharge...Emergency medical condition (EMC) is a medical condition manifesting itself by acute, severe symptoms (including severe pain, psychiatric disturbances, and/or symptoms of [DIAGNOSES REDACTED][Hospital #1] staff should conduct a MSE to determine if an EMC exists..."

3. Medical Record review for Patient #2 revealed the patient presented to Hospital #2 on 10/2/16 at 3:53 PM and was triaged at 4:23 PM. The patient had a gunshot wound (GSW) to the left anterior thigh with no exit wound. The patient's pain intensity at 4:23 PM was 10 on scale of 1-10 with 10 being the worst. The patient was given a tetanus shot and intravenously (IV) Cefazolin.

The x-ray at Hospital #2 revealed no acute bony findings, fractures, dislocations, or degenerative changes, and normal bone mineral density. A single bullet was present in the lateral aspect of the left thigh with surrounding subcutaneous air.

Review of the transfer form for Hospital #2 revealed Hospital #2 had notified Hospital #1 of the transfer of Patient #2 to Hospital #1 and the ED physician at Hospital #1 had accepted the patient transfer on 10/2/16 at 5:52 PM. On page number 2 of the transfer form, under transfer checklist, it was checked that the destination facility, Hospital #1, "has confirmed that the destination facility has available space and qualified personnel to treat the individual and has agreed to accept transfer of the patient".

Review of the ambulance run ticket for Patient #2 revealed the following, "EMT [emergency medical technician] assessment...GSW present to left lower extremity, GSW had no active bleeding present, bullet present to wound, pedal pulse present x [times] 2, no signs of shock present, pain scale 10 out of 10... Upon arrival at destination [Hospital #1] at 19:20 [7:20 PM], pt was placed in hallway of ED [Emergency Department] paperwork handed over, no registration or triage performed. Approx. [Approximately] 20:20 [8:20 PM], crew relief arrived and crew swap completed, Approx 20:40 [8:40 PM], 1 hr and 20 minutes after arrival at [Hospital #1], facility nurse triaged and registered pt. Approx 00:30 [12:30 AM, 5 hours and 10 minutes after arrival] physician came and assessed pt. During extended offload [the time the EMS crew stayed with the patient in Hospital #1's ED], pt complained of pain in her leg at a level of 10/10. Pt received no medication during wait for facility bed. Approx 00:50 [12:50 AM] hrs pt offloaded [transferred] to facility [Hospital #1] stretcher with draw sheet..." The patient remained with the EMS personnel on the EMS stretcher for 5 hours and 30 minutes before being transferred to the care of the ED staff.

Review of Hospital #1 nurses notes for Patient #2 revealed the patient arrived at Hospital #1's ED at 19:24 (7:24 PM) and was rated an ESI acuity level 3 at 19:45 (7:45 PM) by Nurse #1. A triage assessment at 7:52 PM revealed, "...Pain currently is 10 out of 10 on pain scale. Quality of pain is described as aching, Pain does not radiate. Noted to be grimacing..." Review of the vital signs revealed at 20:51 (8:51 PM) a pain level of 10 out of 10. The next vital signs were documented at 1:19 AM 9 (4 hours and 28 minutes later) with a pain level of 10 out of 10. At 1:20 AM the patient was administered Morphine 4 milligrams ( mgs) with Zofran 4 mg intravenously push (IVP) for pain which stabilized her pain from a 10 to a level of 3. This was 5 hours after the patient's arrival to Hospital #1's ED.

On 10/3/16 at 00:51 (12:51 AM) the ED physician documented, "...L [left] thigh GSW, palpable DP/PT [dorsalis pedis/posterior tibial pulses], motor/sensory intact..." At 03:28 (3:28 AM) on 10/3/16, the physician documented the patient was medically screened. This was 7 hours and 8 minutes after the patient's arrival to Hospital #1's ED. At 3:29 AM the physician documented the patient was stable and to discharge home.

During a telephone interview on 10/11/16 at 2:07 PM, EMT #1 verified the information documented on the ambulance run ticket was accurate. He stated, "Pt was a GSW to leg with no exit wound. Transported to [Hospital #1], my partner gave info to nurse [ED nurse at Hospital #1] as we came in and we were told to wait behind other stretchers...waited for several hours, then the nurse got vital signs and assessed...we were behind double doors, in the hallway outside trauma...we were lined up with [name of 2 local ambulance services]...She [Patient #2] was in pain, but not screaming...."

During a telephone interview on 10/11/16 at 4:06 PM, EMT #2 verified the information documented on the ambulance run ticket was accurate. He stated, "I came in at 8:00 PM to relieve [name of EMT] whose shift was over...the patient was stable but in pain...we were lined up in hallway".. EMT #2 stated, "I helped the patient off the stretcher twice to go to bathroom..."

During an interview on 10/12/16 at 7:48 AM in the Administrative Conference Room, RN #2 stated, "...the patient may have been in the shock trauma area if there was no space in CCA [Critical Care Access]. We need doctor's order for pain meds [medications]...If we can talk to a doctor, we will get an order. I remember her, she was very calm, did not act in pain... We typically do VS [vital signs] every 2 hours for most patients. She had good pulses, no signs of [DIAGNOSES REDACTED], she was a very stable patient..."

During an interview on 10/12/16 at 8:10 AM, RN #1, stated, "We were on diversion before she arrived. I was not her nurse...had 6+ stretchers and they [EMS] wanted to off load [take the patient off the EMS stretcher and put them on the hospital's ED stretcher or bed].... She [Patient #2] told me her pain was 10/10 but she wasn't moaning, crying...she was sitting up on stretcher asking about friend who got shot too...There was no drainage from wound...I did ask her to wiggle her feet, no neuro issues. I did her vital signs. I was the house supervisor and was getting stretchers, taking patient to rooms, I triaged her because I have triaged before. I touched on the primary points. I made her an ESI-3 because I did not see her injury...After that I only saw her as I was going through the unit. We went on Surge until about 2:00 AM, I think..." [Surge Capacity may occur when the Emergency Department receives an influx of patients, has patients with a high level of acuity, is holding patients for admission, and exceeds the departmental resources...To outline the procedure when the Emergency Departments have high census with patients requiring admission from the Emergency Departments,patient waiting in triage, incoming transfers, and/or patients awaiting off-loading from Emergency Medical Services (EMS).]

The patient was "parked' on the EMS stretcher with the EMS staff with the patient from 7:20 PM until 12:50 AM, 6 hours after arrival to Hospital #1's ED. The patient's pain was not addressed and stabilized until 1:20 AM, 5 hours and 56 minutes after the patient's arrival to Hospital #1's ED.

4. Medical record review for Patient #7 revealed the patient arrived at Hospital #1 on 9/30/16 at 21:31 (9:31 PM) ambulatory with the chief complaint of being in a motorcycle accident 30 minutes prior to arrival. Review of the Nurse's Notes revealed the patient was triaged at 22:00 (10:00 PM) and assigned acuity level ESI-3 Urgent and was placed in the waiting room. At 23:00 (11:00 PM) the nurse documented, "Triage Assessment: 22:00 - ...Derm: [dermatology (skin)] road rash to left and right forearms, lower back and left knee...Reassessment: This RN to triage and explain to pt cause of extended wait time. Pt a&o [alert and oriented] x [times] 3, follows all commands, no acute distress noted. Dressing noted to rue [right upper extremity]. Pt verbalizes understanding of calling pt back asap [as soon as possible].." On 10/1/16 at 00:45 (12:45 AM), the nurse documented, "available bed in CCA. Pt has been advised of wait. Asked supervisor to speak with pt. CCA on surge plan now. Pt will be first one called back from triage when able. [staff name] will go speak with pt..." The next documentation was at 7:15 AM, 7:30 AM, 7:45 AM - "Patient called every 15 minutes...." There was no documentation of ongoing assessments of Patient #7 from 11:00 PM to 7:15 AM.

5. Review of the transfer form for Hospital #2 revealed Hospital #2 had notified Hospital #1 of the transfer of Patient #9 to Hospital #1 and the ED physician at Hospital #1 had accepted the patient transfer on 10/01/16 at 2:51 AM. On page number 2 of the transfer form, under transfer checklist, it was checked that the destination facility, Hospital #1, "has confirmed that the destination facility has available space and qualified personnel to treat the individual and has agreed to accept transfer of the patient."

Medical record review for Patient #9 revealed the patient arrived at Hospital #1 on 10/1/16 at 3:52 AM via ambulance from Hospital #2 for GSW to right medial knee.

On arrival at Hospital #1, Patient #9 complained of a pain level of 8 out of 10 at 4:08 AM. The triage nurse assigned an acuity level of ESI-3 Urgent at 5:51 AM, 1 hour and 59 minutes after arrival at the hospital. Triage was documented as completed at 5:53 AM. At 5:57 AM the nurse documented, "Patient Interventions: Patient placed in exam room on stretcher in view of nurse on pulse oximetry. Cardiac monitor on. Bed in low position..."

Review of the ambulance run ticket revealed EMS was able to leave the patient at Hospital #1 at 6:00 AM., 2 hours and 8 minutes after arriving to Hospital #1 with Patient #9.

At 6:41 AM, the physician documented the patient was medically screened, 2 hours and 49 minutes after arrival to Hospital #1's ED. The patient's pain was addressed and stabilized at 6:45 AM, 2 hours and 52 minutes after arrival to Hospital #1's ED.

6. Medical record review for Patient #17 revealed the patient presented, ambulatory, to Hospital #1 on 6/7/16 at 3:56 PM with chief complaint, "I was shot in my hand on Friday and told to come back if it wasn't getting better. It's really swollen..." The patient was assigned an acuity level of ESI-3 Urgent at 4:01 PM and triage assessment at 4:02 PM documented the patient had pain currently 8 out of 10 on pain scale. The patient was placed in the waiting room. At 9:52 PM the patient came to the triage desk and stated he was going to leave because he had been here for hours. The staff had the patient fill out a Refusal of Services form and the patient left the facility. There was no documentation from 4:02 PM - 9:52 PM, Patient #17 had an ongoing assessment after arrival to Hospital #1's ED seeking medical treatment. The patient was in Hospital #1is ED for 5 hours and 50 minutes without ongoing assessments or a MSE.