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PARKWEST MEDICAL CENTER 9352 PARK WEST BLVD KNOXVILLE, TN 37923 May 12, 2015
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination for one patient (#6) of twenty-five Emergency Department (ED) patients reviewed.

The findings included:

Review of Hospital #1's Emergency Medical Treatment and Active Labor Act Guidelines, effective date 1/14, revealed, "A Medical Screening Examination (MSE) will be performed for any individual that 1) presents on hospital property and requests examination...The Medical Screening Examination may include...Ancillary testing and/or prior procedures as deemed necessary to rule out the presence of an EMC [Emergency Medical Condition]...Other examinations, tests, or procedures as deemed necessary..."

Medical record review of an Emergency Medical Service's (EMS) Patient Care Report dated 2/26/15 revealed Patient #6 was transported from her home on 2/26/25 at 2:14 AM, and arrived at Hospital #1 at 2:55 AM. Further review of the Patient Care Report revealed the patient was complaining of abdominal pain and vomiting, with blood pressure 130/80 (normal is 119/79 or below), pulse 72 (normal pulse is 60-100), and respirations 16 (normal respirations is 12-20). Further review of the Patient Care Report revealed, "...Transport from residence to Parkwest was without incident...Pt [patient] was unable to ambulate due to pain..."

Medical record review of the ED Record dated 2/26/15, revealed Patient #6 arrived at Hospital #1, by ambulance, on 2/26/15 at 3:04 AM for complaint of abdominal pain. Further record review revealed the patient was triaged at 3:04 AM with blood pressure of 170/97, pulse 142, respirations 18, PulseOx 97% (level of oxygen present in the blood/normal 92-100%), and temperature 99.5 degrees (normal 98.6). Further record review revealed at triage, the patient was complaining of severe pain at level "10" on a scale of 1-10 (1 being mild pain, 10 being severe pain). There was no documentation of any diagnostic tests being ordered or performed. There was no documentation of any medications being prescribed or administered to the patient.

Medical record review of the Physical Exam revealed the patient was seen at Hospital #1 by a Medical Doctor on 2/26/15 at 3:17 AM. Further review of the Physical Exam revealed, "...Alert and oriented and responds appropriately to questions; well appearing; well nourished...A 10 system review of systems was performed and is negative for acute complaints..."

Medical record review of the Discharge Summary dated 2/26/15 at 3:21 AM revealed, "...Primary Diagnosis: Abdominal pain...Disposition decision is discharge; Condition at disposition - stable..."

Medical record review of the physician documentation in the Progress Notes at Hospital #1 on 2/26/15 at 3:30 AM revealed, "...Here with abdominal pain. She no longer has constipation. She is adamant about receiving pain medicines. I am more than happy to order tests and labs to try to dx [diagnose] cause of her pain but I am not comfortable giving her pain medicine. Gave usual abdominal pain unknown cause talk. Discussed with pt evolving symptoms. The patient agrees and understands plan. Will f/u [follow-up] with PCP [primary care physician] in 2-3 days. Will return to ER [emergency room ] if worsening in any way, shape or form..." There was no documentation that the patient refused diagnostic tests. There was no documentation that the patient left against medical advice.

Medical record review of the Disposition note dated 2/26/15 revealed, "...A discharge pain score was documented: Pain 0/10 (no pain) at 4:04..." Further review of the disposition note revealed the patient left the ED at 4:04 AM.

Medical record review of an ED Triage sheet from Hospital #2 revealed Patient #6 presented to Hospital #2 on 2/26/15, at 5:44 AM, complaining of stomach pain and stating, "...we just came from park west and they didn't do anything...". Further review of the triage sheet revealed blood pressure 146/91, pulse 90, temperature 98.9 and pain level "6" on a scale of 1-10.

Medical record review of the Emergency Provider Record at Hospital #2 revealed the patient was seen and examined by a physician on 2/26/15 at 6:15 AM. Further review of the Emergency Provider Record revealed diagnostic tests were performed, which included: Complete Blood Count (CBC/a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia and infections), Chemistry Panel, Urinalysis, and a Computerized Axial Tomography (CT/ a computer assisted x-ray) Scan of the abdomen.

Medical record review of the results of the diagnostic tests performed at Hospital #2 on 2/26/15 revealed the patient's white blood cells (WBC), an indicator of possible infection, was 16.9 (normal range 4.4-11.0), and the CT scan was "...most suggestive of enteritis. Multiple slightly enlarged mesenteric lymph nodes are presumably reactive. A 4.7 cm [centimeter] right ovarian cystic lesion, likely representing an ovarian cyst...Recommend followup with pelvic ultrasound in 6 weeks..."

Medical record review of the Hospital #2 records revealed there was no documentation of the patient requesting drugs or pain medications. Further review of the Emergency Provider Record revealed the patient was admitted to Hospital #2 on 2/26/15 with diagnosis of [DIAGNOSES REDACTED]

Medical record review of a Discharge Summary from Hospital #2 dated 3/6/15, revealed Patient #6 was admitted to Hospital #2 on 2/26/15 with diagnoses which included: Sepsis on Admission, Enteritis, Nausea, Vomiting, Right Lower Lobe Pneumonia, Anxiety, Anemia, [DIAGNOSES REDACTED], Ovarian Cyst, Constipation, Ankle Pain, and Abnormal Urinalysis. Further review of the discharge summary revealed the patient was discharged from Hospital #2 on 3/6/15 (8 days later) in stable condition.

Interview with Patient #6 by telephone on 5/7/15 at 1:30 PM, revealed the patient did remember her visit to Hospital #1 on 2/26/15. The patient stated she did not receive good care on her visit on 2/26/15. Patient #6 stated, "...it was snowing and a fire truck had to pick me up and take me to the ambulance because the ambulance could not make it to my house...I was sick and vomiting in the ambulance..." The patient stated that when she arrived at the hospital, "...the doctor came in immediately and said I can't give you any pain meds...the doctor did no blood tests, no x-rays, no urinalysis, nothing...they discharged me and I couldn't even walk...I was still in pain and vomiting...my mom came and picked me up in the snow...I was also having anxiety...Ask a Nurse [insurance provider's nurse help line] called me back...I was supposed to go to [Hospital #2] but the ambulance took me to [Hospital #1] instead...I told Ask a Nurse that I was still in pain and vomiting and the nurse told me to go to [Hospital #2]...my mom took me to [Hospital #2] and they did lab tests and a CT scan...gave me IV [intravenous] and antibiotics and put me in the hospital for 9 days...they said I had fluid on my lung, dehydration, stomach virus, and a urinary tract infection..." The patient stated she had not been hospitalized or seen a physician since being discharged from Hospital #2.

A second telephone interview with Patient #6 on 5/14/15 at 10:45 AM revealed, "...I was still in pain when I left Parkwest...I did not ask for any pain medicine when I came in, when he told me I was being discharged I told him, 'I am in pain. I can't sleep.' He told me it was against the law for him to give me pain medicine...I did not want to leave but they discharged me and made me go...I had to wait out in the waiting room for my mom to pick me up...then she took me to UT where they admitted me..." When asked about the severity of her pain at discharge the resident described the pain as a "10" on a scale of 1 to 10 with 10 being severe pain and 1 being mild pain. Further interview with the patient, when asked if she had been offered lab tests or xrays by the doctor revealed, "...no they did not offer to do any tests...I did not refuse any tests, they did not offer me any...he just came in and said he was not allowed to give me any pain medicine and that he was going to discharge me..."

Interview with Physician #1 (the MD that saw Patient #6 at Hospital #1 on 2/26/15) by telephone on 5/11/15 at 2:10 PM revealed he did not remember this patient.

Telephone interview with Registered Nurse (RN) #1 (nurse involved in Patient #6's care and discharge on 2/26/15) on 5/11/15 at 2:45 PM revealed, after reviewing the medical record, "...I remember that night...the doctor didn't order anything..."

Interview with Physician #2 (who admitted and treated Patient #6 at Hospital #2 on 2/26/15) revealed he had reviewed Patient #6's medical record and did not remember this specific patient. After reviewing the medical record the physician stated, "...she definitely met criteria for admission...had signs and symptoms of [DIAGNOSES REDACTED]"
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination for one patient (#6) of twenty-five Emergency Department (ED) patients reviewed.

The findings included:


Refer to A2406 for the facility's failure to provide a Medical Screening Exam.