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ERLANGER MEDICAL CENTER 975 E 3RD ST CHATTANOOGA, TN 37403 June 5, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of a facility investigation, medical record review, interview, and observation, the facility failed to provide an appropriate medical screening exam to 1 patient (#1) with an emergency medical condition out of 38 patients reviewed.

The findings included:

Review of a facility investigation dated 4/23/2019 at 7:50 PM revealed Patient #1 went into cardiac arrest in the Emergency Department (ED) waiting room while waiting for treatment and admission to the hospital. Further review revealed "...A [AGE] year old male presented...on April 23, 2019, at 1225 [12:25 PM]. The Patient's chief complaint on presentation was...shortness of breath...The patient was seen by a triage nurse at 1318 [1:18 PM] and a nurse practitioner [NP] evaluated the patient at 1341 [1:41 PM]. The patient relayed having a history of CVA [Cerebrovascular Accident/stroke] with mild residual left sided weakness, CHF [congestive heart failure], alcohol abuse, cocaine abuse (last used Jan. 2019), hypertension, CAD [Coronary Artery Disease], shortness of breath constant for 2 months worsening with exertion, chest pain tightness, cough with yellow sputum, no fevers. The patient was supposed to be on meds [medications], but reported not taking them. On exam, the patient had tachypnea [rapid breathing], his oxygen saturation was OK, with no wheezing heard. The NP's plan was to order a cardiac workup to rule out CHF exacerbation. The NP documented that the patient could have had COPD [Chronic Obstructive Pulmonary Disease]. He reportedly had quit smoking last month and recently saw a pulmonologist with PFTs [Pulmonary Function Testing] completed. After examination, the NP ordered the following diagnostic tests: (1) an EKG [electrocardiogram], (2) CTA [computed tomography angiogram/heart imaging] of chest, (3) laboratory studies, and (4) portable chest x-ray. An IV [intravenous line] was started at 1448 [2:48 PM]. The patient was returned to the front ED area [lobby] to await room placement for admission. The patient was found unresponsive at approximately 1951 [7:51 PM] and resuscitation efforts were initiated. The patient expired at 2114 [9:14 PM]..."

Interview with the Compliance Director on 6/4/19 at 8:00 AM, in the Small Administration Conference Room, revealed the facility completed a detailed investigation of the incident involving Patient #1 on 4/23/19. Continued interview revealed the facility developed and implemented a corrective action plan to achieve compliance with EMTALA requirements. The corrective action plan included:
1. Educate all ED staff on EMTALA requirements. (Interviews with random ED staff during the survey confirmed they had received training on EMTALA requirements and were knowledgeable of EMTALA requirements and review of personnel files and education sign in sheets revealed all ED staff had been educated on EMTALA since the 4/23/19 event)
2. Had updated its NEDOCS (National Emergency Overcrowding Score) ED Response Plan - Overcrowding Algorhythm.
3. The updated algorithm and response plan had been implemented and was currently in use. The response plan included:
a. By the 8:00 AM a list of all inpatients appropriate for hallway beds will be provided during the daily huddle meeting. There will be two patients placed on medical surgical floors beginning at 9:00 AM. The facility remodeled some unused waiting room and office spaces into "hall beds" on each medical floor which will be utilized to move inpatients waiting for discharge and to free up an inpatient bed for an ED admission.
b. ED Bed 8 will be limited to trauma patients except in the case of an active resuscitation.
c. Patient Flow Coordinator (PFC) will continually round to identify and coordinate use of upcoming bed vacancies and maintain close contact with ED staff to determine status of patients waiting in the ED proper and the ED waiting room.
d. Clinical Shift Leader will make continual rounds to identify patient acuity (amount of care needed) levels to determine appropriate staffing levels.
e. If Bed 8 cannot be made available for a patient - notify ED attending to assist and if unable to clear the room notify Trauma Attending and follow Trauma Divert Policy.
f. A NEDOCS score of greater than 250 for two consecutive periods, notify Vice-President.
g. Inpatients awaiting therapy or testing will be scheduled earlier in the day to facilitate their discharge.
h. ED Overflow must be opened for NEDOC score over 141.
i. ED employees will be encouraged to arrive to work 1-2 hours early and stay the entire shift to help cover overflow.
j. Keep adequate numbers of patient stretchers available in the ED hallway for incoming patients.
k. ED staff will assess patients in waiting room every hour to determine if any patients need a stretcher.
l. Additional staffing planned for increased ED census and boarding of admitted patients.

Observation of the ED on 6/4/19 at 8:30 AM revealed there were no patients waiting for admissions in the waiting room. Further observations revealed the ED had 60 beds and there were 41 patients currently in the ED awaiting an inpatient bed. Continued observation revealed 15 patients were awaiting an Intensive Care Unit bed. Further observation of the computerized bed location system revealed there were no available inpatient beds in the facility.

Observation of the ED on 6/5/19 at 10:30 AM revealed there were a total of 68 patients in the ED and 31 of the patients were awaiting an inpatient bed. Continued observation revealed the admitted patients were in beds or stretchers in the ED proper. Further observation revealed 8 ED patients, who had been seen by a Nurse Practitioner, were in the waiting room waiting on results of diagnostic tests to determine their disposition and treatment.

Refer to A-2406 for Failure to Provide An Appropriate Medical Screening Exam.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on policy review, medical record review, facility investigation report, and interviews, the facility failed to provide 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 existed for 1 patient (#1)out of 38 patients reviewed, who presented to the emergency department with complaints of Shortness of breath for 2 months..


The findings included:

Review of facility policy "Baroness Hospital Emergency Department Scope of Services," last revised date 10/2018, revealed "...The ED [Emergency Department] maintains the staff and resources necessary to evaluate all persons presenting to the ED and provides for or arranges the treatment necessary in an attempt to stabilize patients who are found to have an emergency medical condition... In accordance with applicable laws, regulations, and standards...A Medical Screening Examination...The purpose of the MSE is to determine if the patient has an emergency medical condition. "


Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 4/23/19 at 12:25 PM with a complaint of Shortness of Breath. Further review revealed the patient was triaged by a Registered Nurse at 1:18 PM and given an acuity level of 3 (urgent but stable) and was then sent to the ED waiting room. Continued review revealed the patient was taken to a consultation room at 1:41 PM where he was examined by a Nurse Practitioner (NP) at 1:42 PM.

Medical record review of an Electrocardiogram (EKG) dated 4/23/19 at 1:56 PM revealed "...sinus tach [tachycardia/fast heart rate]...inferior q waves [may indicate an old heart attack]...long QT interval (may indicate a life threatening heart dysrhythmia]...non-specific changes..." Continued review revealed the patient was placed back in the ED waiting room after the EKG was complete.

Medical record review of a Nurse's note dated 4/23/19 at 2:48 PM revealed an Intravenous (IV) needle (INT) was inserted into Patient #1 and blood specimens were obtained for laboratory tests, including a B-type natriuretic peptide (BNP/a blood test specific for congestive heart failure and potassium level (K+).

Medical record review of a NP's progress note dated 4123/19 at 2:55 PM revealed "...Pt [patient] still with tachypnea [rapid breathing], cp/sob [chest pain/shortness of breath]. however no wheezing, will proceed with eta [computed tomography angiogram/cardiac imaging] chest rule out pe [pulmonary embolism/blood clot in lung]...dissection [broken artery]..."

Medical record review of a laboratory result for a BNP dated 4/23/19 at 4:32 PM revealed a result of 4,322 (results higher than 100 indicate CHF).

Medical record review of a NP's progress notes dated 4/23/19 at 4:51 PM revealed "...Lasix [diuretic/rids the body of extra fluid] ordered...awaiting [lab test results] that had to be redrawn and eta chest.."

Medical record review of a CTA imaging report dated 4/23/19 at 5:29 PM revealed "...URGENT UNEXPECTED FINDINGS...Multiple filling defects are seen in the lower lobe segments on both sides...Cardiomegaly [enlarged heart], dilated IVC [inferior vena cava/a large blood vessel in the chest], hepatic [liver] veins with reflux of contrast. Right pleural effusion [fluid in right lung]. These findings are concerning for right heart failure..."


Medical record review of a NP's progress note dated 4/23/19 at 5:32 PM revealed "...Per [NP #1]...Will need to be admitted for CHF exacerbation. K+ 6.6 [normal 3.5 to 5.0]. Currently awaiting CT results..." Continued review revealed the NP ordered Lasix 20 milligrams (mg) be administered to Patient #1 on 4/23/19 at 6:20 PM, but there was no documentation the medication was administered to the patient.

Medical record review of a Nurse's progress note dated 4/23/19 at 7:52 PM revealed "...Patient wheeled back to [ED] Bed 8 [from the ED waiting room] with agonal [abnormal gasping] respirations. Unresponsive. NPA [nasal pharyngeal airway] inserted at this time. Pulses weak...


Medical record review of a Physician's progress note dated 4/23/19 at 8:42 PM revealed "...Lactate [blood test for sepsis] 12.71 [normal less than 2.0J...POTASSIUM...5.6 [elevated..." Continued review at 9:21 PM revealed "...history of severe CHF presents with shortness of breath, possible pulmonary emboli on CTA of his chest. Profound elevation in BNP. Was awaiting a bed in the ER when he became unresponsive, convulsive syncope in the [ED] waiting room. Was immediately brought back and placed in room 8, where he was noted to be in PEA [pulseless electrical activity]. CPR [cardiopulmonary resuscitation] was started...Multiple rounds of CPR were performed over an hour...we were unable to get the patient to maintain a pulse for more than 1 minute...after 1 hour it was deemed that further coding of this patient would be considered futile care...he was declared expired..." Continued review of a Physician's progress note at 9:22 PM revealed "...Called to bedside by nursing staff. Patient collapsed in [ED] waiting room and he was immediately taken to bed 8. Patient had an MVA [mechanical ventilator assistance] in place and ventilations assisted. He lost a pulse and CPR was started immediately...Patient had multiple rounds of epinephrine [intravenous medication used to restore heart beat], bicarb [sodium bicarbonate medication used during cardiac arrest]. He received calcium [medication given during cardiac arrest to help restore the heartbeat and magnesium [medication given during cardiac arrest to help restore the heart beat]. He was maxed out on 4 pressors [drugs used to restore and/or raise the blood pressure]...This was ultimately deemed futile...it was decided to call [stop] the code [CPR]...Time of death 2113 [9:13 PM]..." There was a delay in completion of the medical screening examination because the patient had to remain in the waiting room of the ED from the time of arrival till the time of cardiac arrest, which was approximately more than 5 hours. The facility failed to maintain the staff and resources necessary to provide further evaluation and treatment necessary to stabilize patient #1 on 4/23/2019, who was determined to have an emergency medical condition.

Interview with the ED Director on 6/4/19 at 10:00 AM, in the Small Administration Conference Room, revealed the plan was to admit Patient #1 on 4/23/19, but the admission process had not been started because the patient was in the waiting room. Continued interview revealed patients cannot be admitted by the hospitalist group until they were in an ED room. Further interview confirmed Patient #1 did not receive the Laslx 20 mg. Further interview revealed the facility had identified the ED's overcrowding was a critical problem and had implemented a hospital wide procedure change to improve the flow of patients from the ED to inpatient units. Continued interview revealed even though procedural changes had been made, ED patients continued to wait in the ED waiting room waiting on test results when ED beds were not available.


Telephone interview with NP #1 on 6/4/19 at 10:20 AM revealed he remembered Patient #1's ED visit on 4/23/19. Continued interview revealed NP #1 saw Patient #1, examined him in a consultation room, and then the patient was placed in the waiting room to await lab results and for the CTA to be performed by the Radiology Department. Further interview revealed Patient #1 was short of breath, but did not appear to be in any acute distress and his vital signs were stable. Continued interview revealed NP #1 handed off Patient #1 to NP #2 at the change of shift (around 5:00 PM) and at that time Patient #1 was still in the waiting room awaiting an available bed in the ED. Further interview revealed the ED was very busy and Patient #1's placement in an ED room kept getting delayed for patients that were more critical that Patient #1. Continued interview revealed NP #1 frequently examined patients in the consultation rooms and after the examination, if the ED had no available beds, the patient would return to the ED waiting room to await diagnostic tests. Further interview revealed NP #1 was not aware Patient #1 failed to receive the Lasix while in the ED on 4/23/19.


Telephone interview with Registered Nurse (RN)
#1 on 6/4/19 at 11:50 AM revealed RN #1 remembered Patient #1's visit to the ED on 4/23/19. Continued interview revealed RN #1 was told. Patient #1 was short of breath, but was otherwise stable. Further interview revealed the patient had an abnormal BNP and was in heart failure. Continued interview revealed the ED Charge Nurse knew Patient #1 needed a bed, but other critical patients arrived in the ED and Patient #1 remained in the ED waiting room. Further interview revealed RN #1 was told Patient #1 was having trouble breathing and RN #1 proceeded to obtain portable oxygen for Patient #1 before he checked on Patient #1. Continued interview revealed when he checked on Patient #1 he was cyanotic (blue from lack of oxygen), his eyes were closed, and his pulse was weak. Further interview revealed the patient was placed in a wheelchair and immediately transported to ED Bed 8 (the main trauma bed) and at that time the patient was not breathing, was not responding, and did not have a pulse. Continued interview revealed RN #1 and other staff immediately initiated CPR on Patient #1.

Telephone interview with NP #2 on 6/5119 at 10:30 AM revealed she remembered Patient #1's ED visit on 4/23/19. Further interview revealed NP #2 never examined or treated Patient #1 on 4/23/19 and was told Patient #1 was assigned a bed in the ED and was going to be admitted to the hospital. Continued interview revealed other patients continued to arrive in the ED in critical condition and Patient #1 was kept in the ED waiting room. Further interview revealed Patient #1 could not be admitted to an inpatient bed until he was placed in an ED bed, because the hospitalist group cannot admit any patient waiting in the ED waiting room. Continued interview revealed all the ED beds were full on 4/23/19 and there were no beds or rooms available in the ED for Patient #1.