The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TRISTAR CENTENNIAL MEDICAL CENTER 2300 PATTERSON STREET NASHVILLE, TN 37203 Sept. 14, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, facility document review, review of the hospital's Emergency Department (ED) Central Log, medical record review and interview, the hospital failed to ensure each patient who presented on the ED Central Log and received an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed.

The findings included:

1. The hospital failed to ensure each patient who presented on the hospital's ED Central Log, at the time they presented for 1 of 20 (Patient #1) sampled patients.

Refer to 2405

2. The hospital failed to ensure all patients presenting to the ED seeking treatment received an appropriate MSE to determine if an emergency medical condition existed for 1 of 20 (Patient #1) sampled patients.

Refer to 2506
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, facility document review, review of the hospital's Emergency Department (ED) Central Log and interview, the hospital failed to ensure each patient who presented on the hospital's ED Central Log at the time they presented for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act] -Tennessee Central Log Policy" revealed, "...The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination ('MSE') could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted treated, stabilized and transferred or discharged ..."

2. Review of the facility investigation which included an internal email dated 8/6/16 from RN #2 to the ED Director revealed, "...I received a call from [family member of Patient #1] Saturday around 11:30 regarding her niece [Patient #1]. She says she [Patient #1] was seen here Monday August 2nd and discharged with a dx [diagnosis] of kidney stones....She claims she came back Tuesday and was never taken back to a room, given something in the waiting room and told to go home. She says she is now in renal failure and is going to have multiple surgeries...There is nothing in the computer for August 3rd..."

3. The ED Central Log dated 8/3/16 documented Patient #1 presented to the ED, refused treatment and left against medical advice prior to MSE.

4. During an interview in the conference room on 9/12/16 at 11:50 AM, the ED Manager was asked if Patient #1 was documented on the Central Log. She stated Patient #1 was not on the Central Log when she initially pulled it for review. She further stated, "...Once it was determined a possible EMTALA violation, we were instructed by Ethics to add the patient to the log..." She again verified Patient #1 was not documented in the log at the time she (MDS) dated [DATE].
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, facility document review and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED)seeking treatment, received an appropriate medical screening exam (MSE), according to hospital policy to determine if an emergency medical condition existed for 1 of 20 (Patient #1) sampled patients.


The findings included

1. Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act] Tennessee Medical Screening Examination Stabilization", revealed, "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and: 1. the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or 2. a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition...Further, if a prudent layperson observer would believe that the individual is experiencing and EMC, then an appropriate MSE, within the capabilities of the hospital's DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists...If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer as defined by and required by EMTALA...An MSE is required when: a. The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition including where: i. The individual requests medication to resolve or provide stabilizing treatment for a medical condition..."

2. Medical record review for Patient #1 documented the patient presented to the ED at Hospital #1 via private vehicle on 8/2/16 at 5:29 AM with complaints of kidney stones and was triaged at 5:29 AM

ED Physician #1 documented the MSE was initiated at 5:30 AM and the patient complained of flank pain with sudden onset. He further documented, "Onset 2 AM with left flank pain similar to past kidney stones...Vomited just prior to me going into room." Patient #1 reported back pain, lumbar pain and a history of kidney stones.

Nursing notes at 540 AM revealed left flank pain rated 9 .

Laboratory results for Patient #1 revealed the following: Glomerular Filtration Rate- greater than 90 and elevated Neutraphils- 70.6. Urinalysis results revealed: urine positive for blood, urine positive for nitrates, and urine with elevated red blood cells (54), elevated white blood cells (16) and elevated Leukocyte Esterase (trace).

Computerized Tomography of the abdomen and pelvis results documented, "Impression : 4 X [by] 3 mm [millimeter] proximal LEFT ureteral stone with mild LEFT [DIAGNOSES REDACTED]."

The patient received the following medications intravenously: Sodium Chloride, Hydromorphine Hydrochloride, Ketorolac tromethamine, Ondansetron Hydrochloride. At 6:37 AM, the nurse documented the patient was pain free.

The patient was discharged home at 7:15 AM in stable condition with a diagnosis of [DIAGNOSES REDACTED]. Rest ...push fluids ...follow up with your Urologist tomorrow for recheck ...take meds as directed ...return for fever chills dizzy or passing blood in stool or increased pain ...prescriptions written: Percocet 5 milligrams [mg]/325 mg take 1-2 tablets by mouth every 4-6 hours as needed for pain ...Zofran 4 mg...let 1 tablet dissolve in mouth every 8 hours as needed for nausea, vomiting ...Levaquin 750 mg take 1 tablet by mouth each day ...Finish All of This Medication ..."

3. Review of the facility investigation which included an internal email dated 8/6/16 from Registered Nurse [RN] #2 to the ED Director revealed, "...I received a call from [family member of Patient #1] Saturday around 11:30 regarding her niece [Patient #1]. She says she [Patient #1] was seen here Monday August 2nd and discharged with a dx [diagnosis] of kidney stones....She claims she came back Tuesday and was never taken back to a room, given something in the waiting room and told to go home. She says she is now in renal failure and is going to have multiple surgeries...There is nothing in the computer for August 3rd..."

4. Review of 'Patient Notes" for Patient #1 dated 8/3/16 revealed Nurse #1 documented, "PT [Patient #1] CAME TO THE ER STATING THE PERCOCET MADE HER SICK. [ED Physician #2] ORDERED TORADOL 10 MG PO [by mouth] FOR PAIN PRN [as needed] QUANTITY 20. RX [prescription] CALLED TO [name of pharmacy]." Patient #1 was not added to the Central Log, was not triaged and did not receive a MSE.

5. On 8/4/16 at 3:46 PM Patient #1 was admitted to Hospital #2. Review of discharge summary documentation by the Hospitalist revealed Patient #1 was admitted with presenting diagnoses of [DIAGNOSES REDACTED]" yesterday 8/3/16 she had returned to the ED at Hospital #1 after she developed fever/chills ...Today 8/4/16 the abdominal and flank pain increased and she presented to the ED for further evaluation. Urology was consulted and she was taken to surgery for a cystoscopy and stent placement. I&O [intake and output] from PACU [post anesthesia care unit] includes 1200 ml [milliliter] crystalloid, UOP [urinary output] 500 ml, EBL [estimated blood loss] <5 ml. She was marginally hypotensive in the PACU and transferred to critical care."

Further review revealed Patient #1 was admitted to the ICU for pyelonephritis with sepsis and Left ureteral stone, postoperative diagnoses of [DIAGNOSES REDACTED]#1 was discharged home on 8/7/16.

6. During a telephone interview on 9/13/16 at 1:27 PM, Patient #1 was asked about her visit to the hospital ED on 8/2/16. She stated she went to the hospital ED in pain and she felt it was a kidney stone because she had a history of kidney stones. She stated she was given medications and according to an X-ray she had a kidney stone that the physician advised she would pass in 24 to 36 hours. She stated the next day (8/3/16) she was"sick and in a lot more pain." Patient #1 stated that her grandmother called the ED on 8/3/16 and asked to have her medicine changed, because they thought the pain medicine was making her sick. Patient #1 stated her grandmother was told Patient #1 would have to come back to the ED to be seen again She stated she had a fever but she had to wait later in the day for someone to transport her to the ED because she had been taking pain medication. Patient #1 stated when she (MDS) dated [DATE] the registrar at the front desk was very rude. Patient #1 stated she told the registrar she was sick and needed a different pain medication. Patient #1 stated the registrar told her, "There is nothing we can do for you, your doctor is not here..." Patient #1 stated at that point RN #1 opened the door and said 'I remember her, I discharged her'..." Patient #1 stated, "I told them I needed to be seen" Patient #1 stated she had just vomited in the waiting room bathroom and she was holding a green emesis bag when the nurse approached her in the waiting room. Patient #1 stated RN #1 went back to talk to the ED physician, came back out to the waiting room and told her they would change her pain medication. Patient #1 stated the medication Toradol was called in to her pharmacy and she picked it up the same day. Patient #1 stated that the following day 8/4/16, her grandmother called to get her an appointment with a Urologist. She stated when she arrived at the Urologist office, they obtained a urine sample and her temperature was 102.5. She stated she was very sick, in a lot of pain, had fever and even blurred vision She stated the Urologist said she would need emergency surgery because she was septic and he was sending her to Hospital #2 for admission.

During a telephone interview on 9/13/16 at 9:13 AM, RN #1 was asked about Patient #1's visit to the ED on 8/3/16. She stated, "...I heard Patient #1 ask Registrar #1 if she would have to make another co-pay." She stated she looked up and recognized Patient #1 because she had discharged her and she recalled she had a kidney stone. RN #1 stated, "I walked out into the lobby and said What's going on...She [Patient #1] said medicine is making me sick" RN #1 stated she asked Patient #1 which medicine was making her sick. Patient #1 replied the pain medication was making her sick. RN #1 stated she told Patient #1, " I know you have a history of kidney stones...I know you have taken Toradol, would Toradol work for you?" RN #1 stated she told Patient #1 she would need to go back and talk with the ED Physician [ED Physician #2]. RN #1 stated she walked back into the ED, explained to ED Physician #2 that Patient #1 was treated earlier this morning for kidney stones. RN #1 stated ED Physician #2 stated he was not prescribing any narcotics. RN #1 then asked ED Physician #2 if he would prescribe Toradol for Patient #1. RN #1 stated ED Physician #2 agreed to prescribe Toradol. When asked if ED Physician #2 was aware Patient #1 was physically present on the hospital premises, RN #1 stated, "I told [named ED Physician #2] she was in the lobby. She stated, "I didn't think I did anything wrong...she [Patient #1] didn't look sick, she looked good." When asked if it was common practice for patient's treated in the ED to call back for a medication change, RN #1 stated, "If you called back tomorrow, I might say what medication...Yes mam' we would do it...others have done it...put patient on hold, look at history, allergies and talk to physician..."

During an interview in the conference room on 9/13/16 at 11:12 AM, ED Physician #2 was asked what he recalled about 8/3/16, the date Patient #1 presented to the ED. He stated, "What I recall... very busy that day...usually I hear [everything around me] but so busy ...I didn't." When asked what RN #1 told him about Patient #1 he stated, "seen for kidney stones yesterday, can I call in medication..." He stated he told RN #1 he could not call in any narcotics. He stated he agreed to call in Toradol. When asked if it was common practice to change or call in medications for a patient previously treated in the ED, even by another ED physician, ED Physician #2 stated, "It's not uncommon, if it's not a controlled substance...yes we would change the medication." ED Physician #2 stated he thought Patient #1 called on the telephone. He stated he was not aware she was in the ED. He stated, "If I would have known she was here...would have patient check in so we could re-evaluate [the] patient."

During an interview on 9/13/16 at 3:40 PM, the ED Manager was asked what her expectation was when a patient presented to the hospital ED. She stated," ...we assume all are seeking to see the doctor for an emergency medical condition..."

A telephone interview was attempted with Registrar #1 on 9/13/16 at 1:53 PM and on 9/14/16 1:49 PM, with no success.

The hospital submitted documentation indicating that they had reviewed the circumstances and had put corrective actions in place. Additionally, they reported the incident to the Regional Office.

The administration has taken immediate measures to ensure this type of incident will not occur in the future. The following corective action has been or will be taken:

On 08/10/16, the Registrar and ED RN involved in the incident were immediately suspended pending final resolution of the review.

On 08/10/2016, the Ethics and Compliance Officer (ECO), Chief Nursing Officer and Spring Hill ED Director discussed the incident with ED Physician-2 and explained the importance of verifying whether a patient is present in the ED if medical/medication questions are asked by ED staff, even if that means questioning the ED staff member further before providing guidance. ED Physician-2 agreed that if such questions were asked about a patient who was present in the ED, the patient should receive a medical screening examination prior to providing any medical advice or medication changes. ED Physician-2 indicated that if he would have known that the Patient was in the ED, he would have ensured the Patient received an MSE.

On 08/12/2016, the ED RN's employment was terminated.

On 08/16/2016, the ECO, Patient Access/Registration ED Manager, Patient Access/REgistration Interim Centennial Director and Spring Hill ED Director held a department meeting with all Spring Hill ED and registration staff. Leadership discussed the incident, explained how the situation should have been handled and provided EMTALA education.

During the department meeting on 08/16/16, registration staff were assigned the online EMTALA Power Point.

The Patient Access director will ensure that all registration staff will receive education on a quarterly basis.

All registration staff have been assigned the EMTALA Health Stream educational course with a completion date of 08/31/2016.

The Registrar was assigned the EMTALA Health Stream educational course for registrars with a completion date of 09/15/2016.

Review and verification of training documentation and interviews revealed corrective actions initiated included Web-based EMTALA training, beginning 8/16/16, as well as attendance of a live EMTALA training presentation 8/16/16 for employees. The employees unable to attend the live presentation, viewed a recorded version of the EMTALA presentation which was made available after the 8/16/16.
Further review and verification of training documentation and interviews revealed corrective actions also initiated included the following trainings: Reportable Issues Case Studies/Test training 8/16/16, Prescription Medication Practice information initiated 8/11/16 and training related to whether a patient is/not placed on the Central Log was initiated 9/7/1916.
The facility completed a late entry in the ED Central Log, as well as a note documenting the patient presented for treatment 8/3/16 but was not seen.
The contracted Clerk/Registar involved in this incident was given additional training by the contract company with which she is employed.
The contracted Clerk/Registrar involved in this incident was replaced by a different Clerk/Registrar.