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TRISTAR CENTENNIAL MEDICAL CENTER 2300 PATTERSON STREET NASHVILLE, TN 37203 Aug. 27, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #1) sampled patients who was refused care by Hospital #1.

Refer to findings in deficiency A2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical care received a medical screening examination (MSE) to determine if an emergency medical condition existed for 1 of 1 (Patient #1) sampled patients who was refused care by Hospital #1.

The findings included:

1. Review of Hospital #1's policy, "EMTALA - DEFINITIONS AND GENERAL REQUIREMENTS", revealed, "...POLICY: The hospital with an emergency department must provide to any individual, including every infant who is born alive, at any stage of development, who "comes to the emergency department" an appropriate Medical Screening Examination ("MSE") within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition ("EMC") exists, regardless of the individual's ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department ("DED"), when an individual requests emergency medical care on hospital property, other than a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made..."

2. Review of the ED Log for Hospital #1 dated 7/26/14 revealed patient #1 arrived at 5:15 PM. The entry documented the reason for the visit, "THOUGHT SHE SWALLOWED A THUMB TACK." The disposition category documented, "Was refused Treatment."

3. Review of 9 medical records from Hospital #1 for Pt #1 revealed diagnoses of Bipolar Disorder, PICA [an abnormal craving or appetite for nonfood substances], Impulse Control Disorder, Chronic Constipation and Borderline Personality Disorder. The records revealed ED visits on 3/3/14, 5/6/14, 5/10/14, 5/17/14, 5/21/14, 7/14/14, 8/3/14, 8/9/14, and 8/19/14. Seven of the visits were for swallowing metal objects, one was for abdominal pain and one was for swallowing an unknown object.

Review of a Patient Notes document dated 7/29/14 at 8:53AM for Pt. #1 revealed the ED Director documented, "7/28/14 at 12:05pm Attempted to call patient to check on her and see how she was doing. No answer. 7/28/14 at 17:28 [5:28] pm Attempted to call patient again. No answer. 7/29/14 at 8:36 am. Called and spoke with patient. She states she is doing well. She did seek treatment at another facility. I apologized to her for the misunderstanding that occurred on Saturday upon her arrival at our facility. I further explained to her that she was always welcome to come to our facility for any type of medical treatment. Patient thanked me for calling and verbalized understanding."

There was no further medical record documentation of this visit for Pt. #1.

4. Review of a medical record from Hospital #2 for Pt. #1 dated 7/26/14 revealed the pt. arrived at this hospital ED at 6:07 PM. The reason for the visit was the pt. had swallowed an unknown object, possibly a thumb tack. Radiologic examinations did not identify any foreign body and the pt. was discharged home the same day with discharge instructions to return for problems, concerns or pain and to watch her stool for any foreign body.

5. During an interview in the ED physician's office on 8/25/14 at 10:40 AM, the ED Director for Hospital #1 stated she was notified on 7/27/14 that Pt #1 had been refused treatment without a MSE being performed. Security Officer #1 had recognized the patient from a previous incident in March, 2014 and told the staff the patient could not come back on the property unless it was an emergency. She stated the patient was put on the ED log as a late entry with a note that the patient was refused treatment. On 7/28/14 the ED Director had attempted to reach the patient twice via telephone with no answer. On 7/29/14 the ED Director had spoken with with patient.

6. During an interview in the ED physician's office on 8/26/14 at 2:17 PM, Registered Nurse (RN) #1 for hospital #1 stated she was working triage on 7/26/14 when Pt #1 came into the ED. She stated the patient was in no distress and had been at the snack machine located in the ED waiting room. She stated she was told by Security Officer #1 that the patient had a no trespass warrant against her and could not come on the property.

7. During an interview on 8/26/14 at 2:45 PM, RN #2 for Hospital #1 stated she did not see Patient #1 come to the ED attempting to get medical care. She was caring for other patients. RN #2 stated she heard other staff talking about a patient who was denied treatment. RN #2 stated the security officer said Patient #1 had a trespassing warrant against her and could not come on the property. RN #2 stated to another RN that she was "pretty sure we have to screen her..." The other nurse stated if the patient presented to the ED by ambulance then they had to screen her. RN #2 stated she did not agree with the other nurse. RN #2 stated she did not know until after the incident Patient #1 was the patient that had been denied treatment.

8. During a telephone interview on 8/26/14 at 3:00 PM, RN #3 for Hospital #1 reported the following to the surveyors: She was working 7/26/14 when Patient #1 came to ED. The security officer told Patient #1 she had a trespassing warrant and was not supposed to be seen in the facility. The security officer said the patient was not supposed to be on the property unless it was an emergency. RN #3 stated the security officer printed some type of paper from the computer and gave it to the patient's caregivers. The patient and the caregivers left. RN #3 stated when she arrived at ED #1 the next morning, she and some of the other staff talked about the incident. RN #3 stated she had thought about the incident, and she notified her immediate supervisor. RN #3 stated at the time of the incident on 7/26/14 she did not think anything about the patient being asked to leave. She stated it, "sounded so legal... so lawful... that's what threw me..."

9. During a telephone interview on 8/26/14 at 4:00 PM, ED Clerk #1 stated, "I was working and [stated Pt #1's name] came to the ER [emergency room ] and stated she had swallowed some tacks. I was pulled towards the nurses station and told by the security guard [Security Officer #1] and charge nurse [RN #1] that we could not treat her... We were given a piece of paper that said she [Pt #1] could not come on the premises unless in an ambulance. The caregivers [for Pt. #1] were not aware of this either ...I did not read the paper... he [Security Officer #1] said the paper said she could not come here unless in an ambulance..."

10. During an interview in the physician's office on 8/27/14 at 8:30 AM, Security Officer #1 revealed he had worked as an armed security officer with hospitals for 7+ years. He stated in March 2014, Pt #1 came to the ED, received treatment and was discharged . The patient went to the waiting room and was there for about 15-20 minutes, he could hear voices getting louder and that she liked attention. He went to the waiting room and asked her to leave. He tried coaxing her to leave. After 5-10 minutes, she was not budging. She began to get louder and started kicking at the staff. Security Officer #1 stated, "I thought I could bluff her, it didn't work... called police... They came and talked to her for 10-15 minutes too. Even after they told her they would cuff her, she refused to leave. They told her she was under arrest and she left with them. I did not see her again after March until this incident. I was sitting at the desk when I heard her come in and she was giggly and I heard her tell the Registrar, 'I think I swallowed a thumb tack' I printed a copy of my report [incident report] that said she was trespassed from the property." He explained that a trespass warrant is an agreement between the patient, himself [Security Officer] and an officer of the [named the local police department] that agree the patient has trespassed and can't come back on the property. He stated he gave the patient's caregivers a copy of the incident report and they apologized and left with the patient..."

11. During an interview in the physician's office on 8/25/14 at 1:55 PM, the Director of the ED for Hospital #1 stated RN #1 notified her of the event on the morning of 7/27/14. She stated RN #1 told her a patient was denied treatment on 7/26/14.
The Director of the ED stated she reported the incident to her supervisor. She stated the facility had training for all staff after 7/26/14 and after speaking with staff, she felt the staff at the facility knew what EMTALA was, but when the trespass warrant was thrown into the mix, it was confusing for everyone.

Review and verification of training documentation and interviews revealed corrective actions initiated included Security Officer #1 completed a web-based EMTALA training on 7/29/14 and a live presentation on 7/30/14. The three RN ' s involved completed web-based EMTALA training and live training. The remaining ED staff received live EMTALA training on 8/1/14. Annual refresher courses will now be required for all security, ED and labor & Delivery staff. New hire orientation for Security and ED employees has been revised to include EMTALA regulations.
Additionally, the facility indicated in writing that it completed the following corrective actions:
1. Completed a late entry in the ED Central Log noting the patient was refused treatment on 07/26/14.
2. On 07/29/14, the Security Officer completed an EMTALA training course in HealthStream, a web based training module.
3. On 07/30/14, the Security Officer also attended an EMTALA training presentation presented by the Centennial Ethics and Compliance Officer.
4. The three RN's who witnessed the incident completed the EMTALA training course in HealthStream. They also attended and participated in the EMTALA training presentation by the Ethics and Compliance Officer on 07/30/2014.
5. On 08/01/2014, the Ethics and Compliance Officer presented EMTALA training to the remaining Spring Hill ED staff members.
6. All Security staff members at the two other campuses, Centennial Medical Center and Centennial Medical Center-Ashland City, completed the HealthStream EMTALA training course by 08/08/14.
7. The Ethics and Compliance Officer will present an EMTALA training presentation to the ED staff members at the other two campuses by 08/29/14.
8. Annual EMTALA Refresher course will be required for all ED, Security and Labor and Delivery staff members.
9. Centennial's New Hire Orientation for ED and Security staff members has been revised to include a review of EMTALA regulations.