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FORT LOUDOUN MEDICAL CENTER 550 FORT LOUDON MEDICAL CENTER DR LENOIR CITY, TN 37772 Oct. 15, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility policy, medical record review, and interviews, the facility failed to provide a timely triage assessment and a medical screening examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) with Abdominal Pain of 32 ED medical records reviewed.

Findings include:

Refer to A-2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of facility policy, medical record review, and interviews, the facility failed to provide a timely triage assessment and a medical screening examination (MSE) for 1 patient (#1) who presented to the Emergency Department (ED) with Abdominal Pain of 32 ED medical records reviewed.

The findings included:

Review of the facility policy titled, Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines, last revised on 12/2019 showed "...triage: refers to the clinical assessment of the individuals signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be seen by a physician or other qualified personnel [QMP] for completion of the Medical Screening Examination...The MSE...is defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition [EMC] or not. An MSE is an ongoing process that begins with triage..."

Review of the facility policy titled, Documentation and Nursing Care of the Patient in the Emergency Department, last revised 1/2020 showed "...Triage Assessment: Registered Nurse or Provider will complete a triage assessment and triage classification on all patients who present to the Emergency Department. The nature of illnesses and injuries of these patients will govern the classification to assign priorities for a patient's treatment...the Emergency Severity Index (ESI) triage system will be used to prioritize patients presenting to the Emergency Department seeking care...Goals of Triage: (A). A triage assessment completed by a Registered Nurse or Provider as soon after their arrival as is possible (B). Determination of the urgency of need for care...all patients will be assigned a triage classification based on the ESI triage system, upon completion of the triage assessment..."

Review of Facility A's ED Log dated 10/11/2020 showed Patient #1 presented the ED with a complaint of Abdominal Pain on 10/11/2020 at 5:17 PM. The patient left the facility without being triaged and without receiving a MSE on 10/11/2020 at 7:24 PM (2 hours and 7 minutes after arrival).

Medical record review of an ED Nurse's note dated 10/11/2020 at 7:08 PM (entered into the medical record on 10/12/2020 at 12:13 AM) showed "...ED staff alerted house supervisor of patient [Patient #1] cussing, yelling and slaming [slamming] family room [room adjacent to the ED] door due to wait. Day shift supervisor and this RN [Registered Nurse] along with security to address [patient's] erratic behavior. Upon entering family room, pt. [patient] started cussing/verbally abusing staff. R/T [related to] wait. Triage process explained but pt. relayed she 'did not give a [expletive]. I have had COVID for 70 days. I do not wear a [expletive] mask. My appendix is ruptured. I have [expletive] asthma. This [expletives] having to wait. I am a nurse and this is not how you do things'...Pt. continued to berrade [berate] and cuss/verbally abuse staff that was present. Pt. again explained triage process but continued to be verbally aggressive towards staff that was present. [Patient #1] admitted it was the 3rd ER [emergency room ] visit within a week and that she needed Morphine for her 'ruptured appendix'...she was on the tracking board [system used to aid ED workflow] to be triaged and [was] waiting in family room. Pt. noted by visible assessment not to be in respiratory distress, skin was normal for ethnicity, dry, was not pale or diaphoretic [sweating profusely], no decrease by any means in LOC [level of consciousness], up and down in chair while cussing/verbally abusing staff, no active vomiting during this time. Pt. elected to leave on own accord...intact in her full decision making after being made aware of triage process and wait explained...pt. declined to stay and elected to leave on own accord. Security escorted pt. and father out..."

Medical record review showed no documentation a triage assessment or a MSE was completed for Patient #1 on 10/11/2020.

Medical record review of an ED Disposition Document dated 10/11/2020 at 7:23 PM showed the patient left the facility without being triaged.

Medical record review showed Patient #1 presented to Facility's B ED on 10/11/2020 at 9:21 PM and was diagnosed with Abdominal Pain. The patient was treated with intravenous (IV) fluids, medications for pain, nausea, and abdominal cramps, and was discharged home on 10/12/2020 at 12:44 AM.

During an interview on 10/13/2020 at 12:50 PM, the Chief Executive Officer (CEO) at Facility A stated the facility's corporate office received a call from Patient #1's father, who stated the patient was in the ED on 10/11/2020 and the facility refused to treat the patient. The father stated Patient #1 came in with abdominal pain and because the patient was unable to wear a mask, due to her asthma, the staff placed her in the family holding room. The patient's father told the CEO "...they waited over an hour and no one saw [Patient #1]..."

During a telephone interview on 10/14/2020 at 8:30 AM, Patient #1 stated she presented to Facility A's ED on 10/11/2020 around 5:00 PM related to abdominal pain. The patient stated "...when I arrived the girl at the desk told me I had to have a mask and they would not treat me unless I wore a mask. They took me to another room where I had to wait. I waited in that room for over an hour and no one saw me and I got mad...started cussing because I was mad...two nurses came in and told me I was 'pink, warm and dry' and I asked them how they knew that because no one had seen me...they told me they would not see me without a mask and they did not have any face shields...a few minutes later they [nurses] came back in and told me it was best that I leave..." Patient #1 stated she left Facility A and went to Facility B where she was given IV Fluids and medications and discharged home with instructions to follow up with her Primary Care Physician.

During a telephone interview on 10/14/2020 at 1:15 PM, RN #2 stated she was the night shift house supervisor on 10/11/2020 and she was notified by the registration staff that Patient #1 was upset and had been verbally abusive to the staff. RN #2 stated "...[Patient #1] had been placed in the family bereavement room...[because] she refused to wear a mask after she told the staff that she had been COVID 19 positive for 70 days...the ED was very busy at that time...the patient checked in around 5:10 PM...the day shift supervisor had talked to the patient around 5:30 PM related to her [Patient #1] not wanting to wear a mask...placed her in the family room to keep away from other patients. We told the patient she was on the tracking board to be seen and we tried to explain the triage process to the patient...I did tell the patient she was pink, warm, and dry when I saw her...I was using basic observation skills...as a Certified Emergency Nurse...felt my visual assessment was correct...she was not in any acute distress...She kept saying 'you're standing here with me talking to me and my appendix is rupturing'...there was no reasoning with her and anything we said to her made her behaviors worse. We told her she would be seen...we never asked her to leave..."

During an interview on 10/14/2020 at 1:50 PM, the ED Manager stated "...we did not have a triage nurse that day and we were using the 'pull to full' [patients triage at the bedside] for triage. All of the rooms were full with other patients when she [Patient #1] presented...the patient arrived at 5:17 PM and was registered...Any patient who may have chest pain, shortness of breath, stroke like symptoms, or who may have appeared ill would have been assessed by a nurse upon arrival. She did not appear to have any acute needs...She was placed in the family room...she refused to wear a mask. We use the family room for patients who present with respiratory issues or concerns related to COVID. The house supervisor had spoken with the patient around 5:30 PM and made the ED staff aware she [Patient #1] was in the family room. Around 6:45 PM she [Patient #1] became upset and the house supervisors spoke with her..." The ED Manager confirmed Patient #1 was not triaged and did not receive a MSE.