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TENNOVA HEALTHCARE 900 EAST OAK HILL AVENUE KNOXVILLE, TN 37917 July 21, 2017
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy, review of the facility's bylaws, review of the Tennessee Code Annotated 63-7-103, medical record review, review of facility documentation, and interview, the facility failed to provide a Medical Screening Examination (MSE) for 5 Patients (#1,#3, #6, #12, #26) of 30 patients reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment and Patient Transfer Policy" revised on 9/1/13 revealed "...Individual hospitals should determine if their state laws and regulations have any additional or different requirements than those set forth herein and ensure the Hospital's emergency medical treatment, patient transfer policy and procedures are in compliance..." Further review revealed "...labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse midlife, or another Qualified Medical Personnel acting within his or her scope of practice certifies that, after a reasonable time of observation, the woman is in false labor..." Further review revealed "...qualified medical personnel refers to those individuals defined by the Hospital's Medical Staff Bylaws Rules and Regulations and approved by the Hospital's governing board to perform the initial Medical Screening Examinations for those individuals coming to the Dedicated Emergency Department and request an examination or treatment..." Further review revealed "...stable for discharge: a patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or, the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings..." Further review revealed "...Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized...there should be evidence of this evaluation prior to discharge or transfer..." Contiuned review revealed "...the Medical Screening Examination goes beyond initial Triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the order in which patients will be seen, not the presence or absence of an Emergency Medical Condition..."

Review of facility policy "EMTALA Medical Screening Stabilization Policy," last revised 9/1/13 revealed "...when an individual comes, by himself or herself, with another person, or by EMS [Emergency Medical Services] to the Dedicated Emergency Department of the Hospital and a request is made...the hospital must provide an appropriate Medical Screening Examination within the capacity of the Hospital (including ancillary services routinely available in the Dedicated Emergency Department and emergency services offered at outpatient departments or facilities) to determine whether an Emergency Medical Condition exists, or within respect to a pregnant woman having contractions, whether the woman is in active labor..."

Review of facility bylaws "Emergency Medical Screening, Treatment," Transfer, [and] On-Call Roster Policy," not dated, revealed "...Any individual who presents to the Emergency Department...for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel...defined as a physician...licensed physician assistants...nurse practitioners with appropriate qualifications as determined by the medical staff credentialing process to perform medical screening examinations...or...a woman in labor...a registered nurse trained in obstetric nursing where permitted under State Law..."

Review of the Tennessee Code Annotated 63-7-103 "Title 63 Professions of the Healing Arts...Nursing...General Provisions," dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review revealed no specific language Registered Nurses were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act.

Medical record review revealed Patient #1 was admitted on [DATE] at 1:18 PM with a diagnosis of Alcohol Intoxication. Further review revealed the patient was discharged home from the ED on 6/18/17 at 10:20 PM.

Medical record review of an ED Nurses Note dated 6/18/17 at 1:21 PM revealed the patient arrived to the ED by ambulance. Further review revealed "...EMS [emergency medical services] states that patient was trying to run into traffic today and the [named police department] had called EMS to transport patient to hospital for further evaluation...." Further review revealed the patient was triaged as an ESI [emergency severity index] Level 4 indicating the patient was non-emergent. Continued review revealed "...appears distressed. Behavior is anxious...denies pain..."

Medical record review of an ED Physicians Note dated 6/18/17 at 1:46 PM revealed "...presents to the ED via EMS ground with complaints of ETOH [alcohol] abuse. Erratic behavior prior to arrival tried to run into traffic the police called EMS to transport patient...was here earlier in the week on the 17th for similar complaints and has long standing history of chronic alcoholism with presentations for intoxicated behavior...strong odor of mouthwash denies drinking mouthwash screams loudly, he is unable to offer any particular chief complaint sitting up on the examining stretcher..." Further review revealed "...unable to obtain ROS [review of systems] due to altered mental status...vital signs reviewed...clinically intoxicated to the point of being out of control although not physically violent at presentation..."

Medical record review revealed the following laboratory diagnostic testing was ordered on [DATE] at 1:43 PM: ETOH Level, Complete Blood Count (CBC), Magnesium level, and a Basic Metabolic Panel (BMP). Further review revealed the laboratory diagnostic test were not done and were cancelled on 6/19/17 at 4:57 AM (the day after the patient was discharged ).

Medical record review of the ED Medication Administration Record (MAR) revealed a physician's order for Geodon [antipsychotic medication] dated 6/18/17 at 1:48 PM. Further review revealed the medication was administered in the patient's left deltoid.

Medical record review of an ED Nursing assessment dated [DATE] at 1:53 PM revealed "...appears malnourished. Behavior is restless, uncooperative. Pt. [patient] screaming and uncooperative...airway is patent, respiratory effort is even, unlabored..."

Medical record review of an ED Nurses Note dated 8/18/17 at 2:03 PM revealed the patient's vital signs were Blood Pressure (BP) 95/64, Pulse 63.

Medical record review of an ED Nurses Note dated 6/18/17 at 2:12 PM revealed "...pain: reassessment: denies any pain at this time. Patient has not been educated on call light usage nor is the call light within patient's reach at this time as patient remains in hallway...patient awaiting diagnostics at this time...resting quietly, appears to be sleeping..."

Medical record review revealed no documentation of patient observations or assessments between the hours of 2:12 PM until 8:17 PM (6 hours and 19 minutes).

Medical record review of a Physicians Note dated 6/18/17 at 6:00 PM revealed "...may discharge when safely ambulating..."

Medical record review of an ED Medication Administration Record dated 6/18/17 at 8:17 PM revealed "...follow-up: response [for Geodon injection]: anxiety decreased..."

Medical record review of the Discharge Instructions dated 6/18/17 revealed "...diagnosis: alcohol intoxication...follow up instructions: follow up with [named] Walk-In clinic: when...1st available...reason: recheck today's complaints..." Further review revealed "...test and procedures: labs: none..."

Review of an ED Security Camera Video recording, with a secuirty officer, on 6/30/17 at 1:55 PM revealed the following:
* 6/18/17 1:33 PM: the patient was placed in the EMS entrance area, between 2 sets of automatic entrance doors by a nurse
* 6/18/17 1:34 PM: the nurse exited the area and left the patient unattended
* 6/18/17 1:37 PM: the ED Physician examined the patient in the EMS entrance area
* 6/18/17 2:03 PM: Nurse placed a portable cardiac monitor on the patient
* Further review of the video recording revealed several ED staff employees walked by the area where the patient was and the staff did not check on the patient or remove the patient from the EMS entrance area
* Further review of the video recording revealed the patient was taken back into the ED and placed in the hallway at approximately 4:40 PM (approximately 3 hours later).

Review of facility documentation dated 6/21/17 revealed "...patient was brought to the ED via EMS. Patient was noted to be anxious and distressed. Patient medicated with Geodon and was placed into the vestibule of the EMS bay on a [cardiac] monitor..."

Interview with RN #6 on 7/13/17 at 3:05 PM, in the ED Treatment Room, revealed the EMS entrance area was not a designated patient care area. Further interview confirmed "...I know he had orders for labs and they were not done for the patient..."

Interview with the Laboratory Director, on 7/14/17 at 9:50 AM, in the conference room, revealed the ED staff normally draw the blood and send the blood specimens to the lab. Further interview confirmed "...if the test are cancelled there should be an order to cancel them...if they are not cancelled then the computer system automatically cancels the test the next day..."

Interview with RN #7 on 7/14/16 at 10:55 AM, in the ED Nurses Station, revealed "...the physicians order the labs...the nurse's draw the blood...if a patient is being discharged we ask the physician if the labs are needed or not..."

Interview with RN #8 on 7/14/17 at 11:00 AM, in the ED Treatment Room, revealed diagnostic tests which are ordered by the physician and should be completed by the appropriate department. Further interview revealed "...I do not know if the labs were drawn for the patient but the nurse who was assigned to the patient would make sure the blood was obtained...the physician did see the patient but I am not sure what happened after that..." Continued interview revealed the patient was placed in the EMS entrance area by the charge nurse and the area was not a designated patient care area in the ED.

Telephone interview with Physician #1 on 7/14/17 at 2:05 PM, confirmed a medical screening evaluation should be performed for all patients who seek treatment in the ED. Further interview revealed "...I saw the patient that afternoon...[Physician #2] did the initial screening and ordered the blood tests...when I saw the patient he was in the EMS entrance and was lying on a stretcher...he was yelling but not combative...I did not see any labs on the medical record...the orders should be discontinued or cancelled if the labs were not needed or performed...there was no order to discontinue the labs until the next day after the patient was discharged ..." Further interview confirmed "...from a physician's standpoint any labs or diagnostic test should be obtained if they were ordered..."

Interview with Physician #2 on 7/14/17 at 2:45 PM, in the ED Treatment Room, revealed "...the patient frequently comes here with the same complaints...there had not been any labs done for the patient in the last few visits...I thought the labs were needed just as a baseline for the patient related to intoxication...the patient had multiple admissions to the ED with similar complaints..." Continued interview revealed "...the patient's history was given to us by the EMS which revealed the patient had a history of a subdural hematoma...there were no findings related to any acute injury..." Continued interview confirmed "...I did not cancel the labs...the diagnostic were not performed for the patient. Further interview confirmed the patient was discharged without a complete medical screening as ordered by the physician.

Interview with the Director of Nursing (DON) on 7/14/17 at 4:45 PM, in the conference room, revealed "...Physician #1 saw the patient and wrote the discharge orders and the follow-up instructions...the physicians make the final decision if the labs are needed..." Further interview confirmed "...the orders for the labs were cancelled on 6/19/17 [the day after the patient was discharged from the ED...the labs were not performed for the patient..."

Interview with the Chief Nursing Officer (CNO) on 7/14/17 at 4:50 PM, in the conference room, confirmed the laboratory test were not done as ordered by Physician #2.

Telephone interview with RN #9 on 7/18/17 at 8:00 AM confirmed "...the patient did not have any labs drawn...I know there were orders for the labs..."

Telephone interview with RN #10 on 7/21/17 at 3:00 PM revealed the nurse discharged the patient from the ED on 6/18/17. Further interview revealed "...I gave him the discharge summary as provided by the ED physician...there were no labs on the medical record...the blood would have been drawn on the day shift..."

Medical record review revealed Patient #3 (MDS) dated [DATE] at 8:40 PM with a chief complaint of low back pain and pelvic pressure and was transported to Labor and Delivery (L&D) for evaluation. Contiuned review revealed the patient was seen in the Labor and Delivery Triage department on 1/8/17 at 8:40 PM with a diagnosis of Threatened Preterm Labor 22-37 Weeks. Further review revealed the patient was a [AGE] year old female with her third pregnancy at 32.4 weeks gestation and a pain score of 5. Further review revealed no pain medications or interventions for pain were documented.

Medical record review of an Obstetric (OB) Triage Note dated 1/8/17 at 9:09 PM revealed "...contractions: occasional...vaginal exam: dilatation [cervical dilatation]: 0...effacement [process by which the cervix prepares for delivery]: 0...station [how far into the birth canal the baby's head is located]: -4..."

Medical record review of an OB Triage Note dated 1/8/17 at 9:15 PM revealed "...[named physician on phone]...Report given of pt.s [patients] irritability, reactive FHT [fetal heart tones], UA [urinalysis], and pt. complaint. Orders received to send urine for C&S [culture and sensitivity] and discharge home with instructions..." Further review revealed the patient was discharged home at 10:08 PM.

Medical record review of a Discharge Summary dated 1/8/17 at 10:11 PM revealed "...call [named physician] office in AM to schedule appointment. Drink at least 8-10 glasses of water per day..."

Medical record review revealed Patient #3 was not seen or evaluated by a physician while in the facility.

Medical record review revealed Patient #6 (MDS) dated [DATE] with a chief complaint of back pain and vaginal pain. The patient was transported to L&D at 10:13 PM with a diagnosis of False Labor 37 Weeks or Greater. Further review revealed the patient was a [AGE] year old female with her first pregnancy at 38.5 weeks gestation and a pain score of 6. Further review revealed no pain medications or interventions for pain were documented. Continued review revealed the patient #6 was discharged home on 1/23/17 at 11:32 PM.

Medical record review of the Routine L&D Triage Orders dated 1/23/17 at 10:15 PM revealed a telephone order for routine orders [orders approved by the medical staff]. Further review revealed the physician authenticated the telephone order on 2/2/17 at 5:03 PM (7 days after the patient was discharged ).

Medical record review of an OB Triage Note dated 1/23/17 at 10:30 PM revealed "...frequency [of contractions]: occasional...Dilatation 1.5 cm [centimeters]...effacement: 80%..."

Medical record review revealed no discharge instructions were documented in the medical record and Patient #6 was not seen or evaluated by a physician while in the facility.

Medical record review revealed Patient #12 (MDS) dated [DATE] with a chief complaint of vaginal discharge and was transported to the L&D unit for evaluation at 10:15 PM with a diagnosis of False Labor 37 Weeks or Greater. Further review revealed the patient was a [AGE] year old female with her second pregnancy at 38.5 weeks gestation, with contractions every 6 minutes, and a pain score of 8. Further review revealed the patient was discharged home on 2/24/17 at 11:20 PM. Further review revealed no pain medications or interventions for pain were documented.

Medical record review of an OB Triage Note dated 2/24/17 at 10:19 PM revealed "...rupture of membranes: pt. stated she had thick white pasty d/c [discharge], had a little this morning, and about 30-45 minutes ago she had a lot more, did not have a gush of fluid, is not wearing a pad, and still not leaking..." Further review revealed "...contractions: occasional...frequency: 6 minutes...effacement: 2.0...station -3..."

Medical record review of a physician's telephone order dated 2/24/17 at 11:00 PM revealed "...discharge home...follow-up 3/3/17..."

Medical record review revealed Patient #12 was not seen or evaluated by a physician while in the facility.

Medical record review revealed Patient #26 (MDS) dated [DATE] with a chief complaint of Abdominal Pain and was transported to the L&D Unit for evaluation. Continued review revealed the patient was seen in L&D at 2:45 PM with a diagnosis of Abdominal Pain. Further review revealed the patient was a [AGE] year old female with her first pregnancy at 14.6 weeks gestation with a pain score of 8 on admission to the Triage. Further review revealed the patient was discharged home on 6/19/17 at 7:25 PM.

Medical record review of an OB Triage Note dated 6/19/17 at 2:53 PM revealed "...assisted up to bathroom. UA collected. Pt. moaning and shivering..."

Medical record review of the Routine L&D Triage Orders dated 6/19/17 at 2:55 PM revealed a physician's telephone order for LR [lactated ringers] 1000 ml [milliliter] bolus and then 125 cc/hr [cubic centimeters per hour].

Medical record review of an OB Triage noted dated 6/19/17 at 3:01 PM revealed "...Fetal Heart Tones [FHT's] 140 by Doppler..." Further review revealed at 3:02 PM "...[named physician] on phone to give update and pain score..."

Medical record review of a Physicians Order dated 6/19/17 at 5:15 PM revealed "...10 mg [milligrams] Morphine [pain medication] IM [intramuscular] x 1 PRN for pain...12.5 mg Phenergan [medication for nausea and vomiting...]"

Medical record review of the Medication Reconciliation Record (MAR) revealed the patient received Morphine 10 mg IM and Phenergan 12.5 mg IM at 5:45 PM.

Medical record review of a Physicians Order dated 6/19/17 at 6:40 PM revealed a telephone order for LR bolus x1 now..."

Medical record review of a Nurse's Note dated 6/19/17 at 6:50 PM revealed "...second IV bolus hung per [named physician] request..." Further review revealed "...patient resting at this time..."

Medical record review of a Nurse's Note dated 6/19/17 at 7:00 PM revealed "...[named physician] informed of patient status, new discharge orders noted..."

Medical record review of a Physician's Order Sheet dated 6/19/17 at 7:00 PM revealed "...discharge home...follow up with next appointment or sooner PRN [as needed]..."

Medical record review of a Discharge Summary dated 6/19/17 at 7:04 PM revealed "...follow-up next appointment or sooner if needed..."

Medical record review revealed Patient #26 was not seen or evaluated by a physician while in the facility.

Interview with Registered Nurse (RN) #1 and RN #2 on 7/14/17at 11:11 AM, in the conference room, revealed patients who come into the ED with abdominal pain or complaints related to labor are initially triaged in the ED and then sent to the L&D for further examination. Further interview revealed "...the facility's bylaws states the L&D RN do the assessment and then call the doctor...they have to work in L&D for 1 year...the RN can do a medical screening to rule out labor...this includes a vaginal exam and check for dilatation..." Further interview revealed "...the nurse does the examination and calls the MD...if the patient does not have an established primary physician the doctor has to come in..." Further interview at 11:50 AM, in the conference room, confirmed the physicians did not do the MSE for Patient's #3, #6, #12, and #26.

Telephone interview with RN #3 on 7/14/17 at 3:05 PM revealed "...we get the patients from the ED...they go to triage...a urinalysis is obtained...place the patients on a fetal monitor and do a quick assessment...we call the physician for further orders..." Continued interview confirmed "...we have parameters we follow...the physician does not assess the patient..."

Telephone interview with RN #4 on 7/14/17 at 3:16 PM revealed "...the patient comes from the ED to the triage in a wheelchair...I ask what they came in for and we [nurses] decide if the patient has an emergent need..." Further interview revealed "...the nurses make the decision based on examination and guidelines...we place the patient on a fetal monitor and then call the provider after we assess the patient..."