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.

DECATUR COUNTY GENERAL HOSPITAL 969 TENNESSEE AVE S PARSONS, TN 38363 Jan. 16, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on policy review, medical record review, review of electronic communications and interviews, the hospital failed to ensure all patients presenting to the Emergency Department (ED) received an appropriate Medical Screening Examination (MSE) in order to determine if an emergency medical condition existed so appropriate stabilization, treatment or transfer could be provided within the capabilities of the hospital for 1 of 20 (Patient #3) sampled patients.

The failure of the hospital to provide an appropriate and ongoing MSE posed a SERIOUS AND IMMEDIATE THREAT to all patients presenting to the hospital's ED seeking medical treatment.


Refer to findings at 2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, review of Emergency Medical Services (EMS) Patient Care Record, review of electronic communications and interviews, the hospital failed to ensure all patients presenting to the Emergency Department (ED) received an appropriate Medical Screening Examination (MSE) within capabilities of the hospital to determine if an emergency medical condition existed and ensure all emergency medical conditions were treated for 1 of 20 (Patient #3) sampled patients.

The findings included:

1. Review of the facility's EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT) policy revealed, "...EMTALA is a federal law that requires hospital emergency departments to medically screen every patient who seeks emergency care and to stabilize or transfer those with medical emergencies...EMTALA defines an emergency as an emergency medical condition is defined as "a condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED]."...EMTALA applies to all aspects of emergency care, including specialists, all available tests and procedures and anything else necessary to determine or stabilize an emergency medical condition...".

Review of the facility's MEDICAL SCREENING EXAM policy revealed, "...The purpose of the MSE [Medical Screening Exam] is to determine if an emergency medical condition exists. An emergency medical condition is any condition that might result in death or permanent compromise to an organ or body part in the event stabilizing care is not rendered in a timely manner...The MSE should include the following: 1. Assess chief symptoms (Is this a minor complaint, a chronic condition, at risk condition, or a true emergency?) 2. Vital signs 3. General appearance (Does the patient look sick) 4. Mental status change (Focused mental exam as needed per presenting complaints) 5. Degree of pain (Is their pain moderate or severe?) 6. Skin (Is there evidence of dehydration or poor perfusion?) 7. Focused physical exam results 8. Ability to ambulate...The attending provider should document (if possible) the presence of an emergent condition...In clear-cut cases when an emergency does not exist, the Provider should document this as well. It is the attending provider's responsibility to advise the patient of non-emergent status and explain this to the patient...".

2. Medical record review for Patient #3 revealed a [AGE] year old male with diagnoses that included [DIAGNOSES REDACTED]

On 1/3/2020 Patient #3 called 911 for Emergency Medical Services (EMS) due to shortness of breath unrelieved by a breathing treatment.

Review of the EMS Patient Care Record dated 1/3/2020 revealed EMS arrived at the patient's home at 12:10 PM and found him seated in an electric wheelchair using Oxygen (O2) at two liters per minute. Patient #3 told EMS he had a cough for the past two days and was short of breath.
EMS staff documented Patient #3 was alert and oriented times 4 (awake, alert, and oriented to date, place, person and situation).
Patient #3 reported he had a scheduled appointment with his medical provider on 1/3/2020, but his Oxygen level dropped to 84% (normal being 95 - 100%) and he called 911.
Patient #3 stated he took his breathing treatment about an hour prior to EMS arrival with no improvement.
Patient #3 was able to stand unassisted and move onto the EMS gurney, and O2 was then administered at 2 liters per minute.
EMS staff documented Patient #3's O2 saturation (sat - the amount of oxygen in the blood, with normal being 95 - 100%)) dropped to 88% for a couple of seconds then back to 96-98%, while in route to the nearest hospital. EMS recorded Patient #3's vital signs as Blood Pressure (BP) 100/59, Pulse 76, Respirations 22 and O2 sat as 97%.
Patient #3 was transported to Hospital #1 for further evaluation. Patient #3 remained stable throughout the EMS transport with no changes. EMS staff documented Patient #3 was able to move himself unassisted in a sliding motion over onto the Emergency Department (ED) bed. Patient #3's care was transferred to Hospital #1 ED staff.

3. Review of Patient #3's medical record at Hospital #1 revealed the patient arrived at the ED on 1/3/2020 via EMS at 12:38 PM with complaints of shortness of breath.

The nurse initiated triage (an initial evaluation of the patient) at 12:40 PM and an Electrocardiogram (EKG - a test that evaluates the activity of the heart) was ordered. The triage nurse documented Patient #3 was lethargic (an abnormal state of drowsiness), oriented times 3 (awake, alert and oriented to date, place and person), had even and unlabored respirations and was wearing O2 at 2 liter per minute by nasal cannula. The nurse further documented the patient was using his abdominal accessory muscles (this is a sign of an abnormal or labored breathing pattern). The nurse documented the patient's heart rate was a normal sinus rhythm with PACs (premature heartbeats) noted, bilateral lower extremities were edematous (swelling due to fluid accumulation), and a red lesion noted to left lower extremity.
The patient's vital signs during triage were documented as, Temperature 98.3, Pulse 72, respirations 22, BP 106/47, O2 Saturation 97% with O2 at 2 liters per minute. Patient #3 reported no pain. Nurse notes further revealed the patient's general appearance as, "Appears in poor health, Left Lung sounds: Wheezes [rattling sound in the lungs as a result of obstruction in the air passages], Right Lung Sounds: Wheezes, Edema: 3 plus pitting edema [observable swelling of body tissues due to fluid accumulation in a body part that may be demonstrated by applying pressure to the swollen area, such as by depressing the skin with a finger. If the pressing causes an indentation that persists for at least 3 seconds after the pressure is released] bilateral lower extremities".

Family Nurse Practitioner (FNP) #1 performed a MSE at 12:55 PM and documented the patient complained of Dyspnea with symptoms of [DIAGNOSES REDACTED]#1 further documented Patient #3 was oriented times three, drowsy but easily aroused and had a Glasgow Coma Scale of 15 (a scale that measures a person's state of consciousness on a scale of 3 - 15, with 3 indicating deep unconsciousness and 15 indicating the person is functioning well). FNP #1 documented "no lower extremity edema" [inconsistent with the triage nurse documentation of 3 plus edema to lower extremities and inconsistent with her own prior documentation in the medical record].

Abnormal lab results were documented as follows:
Potassium- 5.3 (normal 3.5-5.1).
BUN- 86.0 (normal 7.0-18.0 blood urea nitrogen appears elevated if there is an elevated level of urea in the blood. It is associated with kidney function, severely dehydration or acute kidney disease).
Glucose 182 (normal 74-106).
Creatinine 4.86 (normal 0.70-1.30 creatinine is a waste product that forms when creatinine, which is found in your muscle, breaks down. creatinine levels in the blood can provide your doctor with information about how well your kidneys are functioning).
Anion Gap 16.9 (normal 5.0-15.0).
A/G ratio 0.9 (normal 1.2-2.5).
FNP #1 ordered for Arterial Blood gases (ABGs - shows how well the lungs, kidneys and heart are working) but the order was discontinued, so no results were available. There was no documentation why the ABGs were not performed.

EKG results revealed, "Sinus rhythm...cannot rule out Anteroseptal infarct (part of the heart dies due to lack of blood flow).

Review of the chest X-ray results revealed, "There is poor visualization of the right lung base...poor visualization of the lung in the left lung base likely related to hypoventilatory changes accentuated by overall poor expansion and some rotation of the chest...otherwise, essentially stable chest since 12/19/19 (previous X-ray)...".

Review of a typed messages sent to the Patient #3's family member by RN #1 on 1/3/2020 at 4:35 PM regarding Patient #3 revealed , "Something is making him Lethargic". The family member responded, "What do you think it is, he takes Xanax and pain meds." RN #1 responded "IDK [I don't know] Does he take them like they are prescribed or just when he wants to?" The family member responded, "When he wants to you know how he is" There was no response from RN #1 and the electronic conversation ended.
There was no documentation of further assessment or investigation by RN #1 into what was making Patient #3 lethargic. There was no documentation that RN #1 notified FNP #1 of the conversation with Patient #3's family member.

FNP #1 documented the final Impression as Dyspnea (difficulty breathing), COPD Exacerbation (acute increase in the severity of a problem), CHF and Patient #3's condition as "Stable" and the plan was discussed with Patient #3 to continue with his nebulizer and inhalers as directed and to follow up with his primary care provider. Patient #3 was discharged home from Hospital #1 on 1/3/2020 5:12 PM.

On 1/3/2020 at 8:18 PM, the family member electronic messaged RN #1 to inform her that immediately following discharge from Hospital #1, Patient #3's son had taken him to Hospital #2's ED and he was admitted to the hospital. RN #1 responded, "Good. What did they admit him for? You know I have no control over what the providers [FNP] do." The family member responded, "His kidneys are failing they said he's full of fluid. Waiting on the rest of the report. I know how it is there [Hospital #1]." RN #1 responded, " I told him [Patient #3] I thought it was his kidneys. I told the provider [FNP#1] that too because he had that jerk that he does when his electrolytes are off." The family member responded, "That's true. I just don't understand how he sit in that ER [Hospital #1] all day with no sign of help whatsoever and badly sick as he was [named Patient #3's son] is very upset over it, he [Patient #3] was drowning in fluid....and I know there's only so much you can do cause [because] you have a provider that does all the orders, but I don't get how provider just neglected him and sends him home with a chf [CHF] diagnosis..." RN #1 responded, "I can't ask for anything either when I see something because it offends the providers. So it's like we [nurses] have to step lightly and just do what we are told. I got in trouble when I first started working here because they said I come in questioning the providers..." The family member responded, "I understand. I just wonder what is making him so lethargic as well." RN #1 responded, "If you aren't getting oxygen you need to the brain it will make you lethargic."

4. Review of Patient #3's medical records from Hospital #2 revealed the patient arrived at the ED at 6:41 PM, approximately 90 minutes after his discharge from Hospital #1's ED, with complaints of general weakness. Triage was initiated at 6:42 PM. The Triage nurse documented, "Child [Patient #3's son] states...they got patient seen at [named Hospital #1] ER [emergency room ] today and they were going to send him home. Patient is too weak to stay at home. States they did not give him any medications to take. Was taken to [Hospital #1] ER by ambulance this morning from home because he was weak and SOB [Shortness of Breath]. Has COPD. Was diagnosed with [DIAGNOSES REDACTED]" At 6:48 PM Patient #3's O2 saturation was 91 % with 3 liters of Oxygen per minute.

A Medical Screening Exam was initiated at 6:58 PM. The ED physician documented Patient #3 reported weakness and dyspnea for the past few days, was treated at [Hospital #1] ED and was getting worse. The ED Physician documented the patient had Rhonchi and wheezing. ED Physician orders included CBC (complete blood count - a blood test used to evaluate the overall health and detect a wide range of disorders, including infection, anemia, etc.), CMP (comprehensive metabolic panel - blood test that aids in determining how the liver and kidneys are functioning and where glucose [sugar], calcium, protein, sodium, potassium, and chloride levels stand), troponin (a protein found in the blood that indicates a heart attack has occurred; normal level is between 0 and 0.4 ng/ml [nanograms per milliliter]), BNP (a blood test that measures level of a protein that indicates heart failure, normal level is less than 100), Chest Xray and EKG.

Chest X-ray results revealed Mild Cardiomegaly (enlarged heart).
The EKG results revealed Undetermined rhythm, pulmonary disease pattern ST and T wave abnormality consider lateral ischemia (usually related to the blockage of blood flow in the heart).
ED lab results revealed BUN- 85, Creatinine- 4.74, GFR-12 (Glomelular filtration rate is a test used to check how well the kidneys are working. Kidney Failure indicated in GFR less than 15).

At 7:56 PM, the ED Physician documented Patient #3 would be admitted for observation with improved but guarded condition. A Duoneb (medication used to treat COPD) breathing treatment was administered at 8:29 PM with improved respiratory status. At 8:43 PM Lasix (medication that relieves fluid build-up) 40 milligrams was administered intravenously.

Patient #3 left the ED at 8:43 PM and was admitted to Hospital #2 for observation and treatment.
Patient #3's History and Physical from Hospital #2 revealed "...[AGE] year old male with several days of severe progressive shortness of breath, weakness, lethargy, confusion and general malaise. History limited by patient's lethargy and confusion...Patient been seen at [Hospital #1] earlier in the day and discharged with diagnosis CHF. Patient apparently was too weak to stand unassisted. Brought to [Hospital #2's] ER...seen by ER doc [doctor] on duty who found patient to be extremely ill appearing. Patient is found to be hypoxic with oxygen saturation 91 % on 3 L [liters] oxygen by nasal cannula, no records available from previous ER visit. Patient is found to be in acute renal failure with BUN 85 and creatinine 4.74 and GFR 12. Chest X-ray showed Cardiomegaly and hilar infiltrates in BNP 3324 [normal values 0-125 Brain natriuretic peptide (BNP) test is a blood test that measures levels of a protein that is made by your heart and blood vessels. BNP levels are higher than normal when you have heart failure.) Due to multiple medical problems and risk factors and the severity of the admission problems and multiple serious co-morbid illnesses it was deemed necessary to admit the patient."

The patient's physician further documented, "Patient was originally admitted to observation telemetry status...upon my medical evaluation this am [morning] patient was changed to full medical in-patient telemetry. Patient's condition has worsened and it is deemed necessary to transfer patient to a tertiary level of care...Plan 1. Acute hypoxic/hypercapnic respiratory failure [a person does not have enough oxygen in the blood, but the levels of carbon dioxide are close to normal] . Patient's condition worsened after admission blood gas this morning shows in uncompensated respiratory acidosis [a condition that occurs when the lungs can't remove enough carbon dioxide. Excess carbon dioxide causes the pH of blood and other bodily fluids to decrease, making them too acidic)with symptoms being with abnormal laboratory results as follows: pH 7.275, PCO2 55.6, PO2 63, bicarb 25.8 and saturation of 88%on 3 L oxygen. Patient was changed to Bipap [a breathing device used to provide extra respiratory support ]10/5 at 40% due to poor airflow and respiratory effort. Oxygen saturations improved to 97%...Patient needs transfer to tertiary level of care with specialty available and ICU [Intensive Care Unit] ....Acute Renal Failure: Patient has no listed record of renal failure of insufficiency. On admission patient had GFR 12 with a creatinine clearance of 15.09. On repeat chemistries only slight improvement on BUN/creatinine, 83 and 4.38 with GFR 14. There is a concern for high-dose loop diuretic and kidney failure....call placed [named Hospital #3] transfer center..."

5. Patient #3 was transferred to Hospital #3 on 1/4/2020 via EMS ground unit.
Review of the EMS Patient Care Record dated 1/4/2020 revealed the patient was picked up from Hospital #2 at 1:55 PM with a documented chief complaint as CHF with secondary complaint respiratory distress. The EMS record revealed, ..."Upon arrival ...[AGE] year old male lying in bed with Bipap on...Foley catheter in place...patient complaining of respiratory distress..." Patient #3 was transported via lights and sirens to Hospital #3 in stable condition throughout transport and arrived at Hospital #3 at 3:47 PM.

6. Review of Patient #3's History and Physical dated 1/4/2020 from Hospital #3 revealed, Patient #3 had a history of chronic diastolic distal heart failure, hypertension, diabetes, COPD, coronary artery disease who presented to the hospital as a transfer from an outlying facility (Hospital #2) with respiratory failure and renal failure. The patient was last admitted to Hospital #3 in 2017 with CHF, however, at that time his kidney function was normal. The record further documented,"... apparently, early yesterday morning he was seen by EMS and was taken to [named Hospital #1] where he stayed a period of time but the family reports they did not do anything for him and he was getting worse, so they picked him up and took him to [Hospital #2]. He [Patient #3] was admitted overnight at hospital #2 but evaluated early this morning and his condition was concerning so he was transferred here. He is now admitted to our Intensive Care Unit. Have reviewed labs and imaging from outlying facility. Notable for Creatinine 4.4, lactic acid of 0.6 pro BNP of 3300, a chest X ray which vascular congestion but no frank pulmonary edema or pneumonia. He is confused. He is irritable and not very cooperative. Mostly complains of short of breath. Family also denies that he has had renal failure. They also state he was diagnosed with [DIAGNOSES REDACTED]"
The Assessment/ Plan was documented as admit to Hospital #3 with hypercarbioc respiratory failure and acute renal failure. Creatinine 4.4 at the outlying hospital (Hospital #2) from a baseline of around 1.2 on his last labs at this hospital in 2017.

Review of the discharge summary from Hospital #3 revealed Patient #3 was discharged on [DATE] with diagnoses of [DIAGNOSES REDACTED]

7. During a telephone interview with Patient #3's son on 1/13/2020 at 11:55 AM, the patient's son stated when he arrived to pick his father (Patient #3) up from the ED at Hospital #1 on 1/3/2020, the patient was very lethargic. The son stated when he walked in to the hospital, he met RN #1 in the hallway and the RN stated Patient #3 was "pretty weak so he might need to get a wheelchair from the hallway."
The patient's son stated he got his father dressed and into a wheelchair without hospital staff assistance. He stated his father was weak and that RN #1 and his wife had text messaged back and forth on 1/3/2020 about Patient #3's condition and discharge from the ED.
The patient's son acknowledged he would share the electronic typed messages with the surveyor and that there was evidence his father was lethargic when he was discharged from the ED.
Patient #3's son further stated his father had a history of COPD and CHF but he had no issues with his kidneys prior to 1/3/2020.
He stated he picked his father up from Hospital #1's ED on 1/3/2020 at approximately 5:30 PM, and transported him to Hospital #2's ED, where he was admitted and later transferred to a higher level of care due to the severity of his condition.

During an interview with RN #1 on 1/14/2020 at 1:30 PM, the RN stated she had been employed at Hospital #1's ED since September 2019. RN #1 verified she was working in the ED when Patient #3 presented via EMS on 1/3/2020. RN #1 stated she was familiar with Patient #3 and she had cared for him as a home health patient in the past 6 months.
When asked how the patient was at discharge RN #1 stated, "Pissed off."
RN #1 was asked if Patient #3 was lethargic at discharge, and she stated the patient was more awake because he was lethargic when he first arrived at the ED. RN #1 stated, "He [Patient #3] was not lethargic when he left."
RN #1 stated the patient's son picked him up from the ED on 1/3/2020, and that she had offered to help get Patient #3 up and out of the ED, but his son stated he didn't need assistance.
RN #1 stated Patient #3's daughter in law electronically messaged her about Patient #3 on 1/3/2020 and they had a conversation via electronic messenger about Patient #3's condition and discharge.

During a telephone interview on 1/15/2020 at 2:03 PM, FNP #1 verified she was on duty on 1/3/2020 when Patient #3 presented to the ED. The FNP stated she had treated Patient #3 in the ED prior to 1/3/2020 and was familiar with Patient #3. The FNP stated the patient came in by EMS with Dyspnea, a dry cough and some edema. The FNP stated Patient #3 reported walking and lying down made the cough and shortness of breath worse.
When asked about Arterial Blood Gas results, the FNP stated the lab was unable to obtain them, so the order was canceled.
When asked what treatment or medications Patient #3 received, FNP #1 stated Oxygen and a breathing treatment. When asked how she determined what tests and labs to order based on his presentation FNP #1 stated, "We have standards of care for COPD and CHF...we check for Pneumonia...There are things we do every time [based on patient complaint] and you have to look at... assessment...what you are seeing and hearing..."
The FNP stated Patient #3 had a normal chest X-ray, his lungs were clear and he had no infection. She stated his BNP (Brain natriuretic peptide test is a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels) was 189 but that was not out of ordinary for a "chronic CHF'er" The FNP stated Patient #3 did not have any edema and he improved after the breathing treatment.

FNP #1 verified she did not contact Physician #1 (her preceptor and supervising physician) or Physician #2 (Hospitalist) to discuss Patient #3 prior to discharge.
When asked specifically about his BUN level of 86.0 and Creatinine level of 4.86 she stated, she instructed him at discharge to follow up with his primary care physician and she did not have any comparison labs.

The surveyor referenced another Hospital #1 ED visit from 8/8/19 during the interview and asked FNP#1 if she had access to these labs when Patient #3 was in the ED on 1/3/2020. FNP #1 verified she had access to the 8/8/19 labs. The surveyor explained that on 8/8/19 Patient #3's BUN was 41.2 and his Creatinine was 1.92. The FNP verified that was significant change but he had no other symptoms with the labs and she told him to follow up with his physician. FNP #1 stated Patient #3 could have been starting renal failure and his primary care physician could repeat the lab tests and refer him to a specialist. FNP #1 stated she felt it was appropriate to discharge Patient #3 home to follow up with his primary care physician.

During a telephone interview on 1/16/20 at 9:04 AM, Physician #1 verified he was the preceptor physician for FNP #1 at Hospital #1. The physician verified he had reviewed the ED record for Patient #3 dated 1/3/2020 and identified no concerns and felt FNP#1 treated Patient #3 appropriately. The physician stated he is generally consulted on cases that required transfer to a higher level of care or admission to Hospital #1.

When asked specifically about the BUN on 8/8/19 of 41.2 that increased to 86.0 on 1/3/2020 and the Creatinine on 8/8/19 of 1.92 that increased to 4.86 on 1/3/2020, Physician #1 stated, " He [Patient #3] had a history of Chronic Kidney disease [there was no evidence in the medical record Patient #3 had a history of Chronic kidney disease] ...she referred him back to his Primary Care Physician..."