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BLOUNT MEMORIAL HOSPITAL 907 E LAMAR ALEXANDER PARKWAY MARYVILLE, TN 37804 June 7, 2021
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of facility policy, review of the Emergency Department (ED) central log, medical record review, review of facility surveillance videos, and interview, the facility failed to ensure a medical screening exam (MSE) was completed for 1 patient (Patient #30) who presented to the ED with complaints of syncope, nausea, and abdominal pain with pregnancy of 30 ED patients reviewed.

The findings include:

Medical record review of a Nurse's Triage Assessment at Facility A's ED showed Patient #30 arrived at the ED on 5/17/21 at 6:03 PM via private vehicle with a complaint of Syncope, Nausea, and Abdominal Pain. The patient was also 18 weeks pregnant. Patient #30 was seen by a Nurse Practitioner while in triage and an ultrasound, labs, and intravenous (IV) fluids were ordered for the patient, which were completed while the patient remained in triage. There was no documentation a physical assessment or a medical screening exam (MSE) was completed by the Nurse Practitioner for Patient #30. The patient was placed in the ED waiting room after the diagnostic tests were completed and she remained there until 8:46 PM, at which time she left the ED and went to Facility B for treatment.

Refer to A-2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of facility policy, review of an Emergency Department (ED) central log, medical record review, review of facility surveillance videos, and interview, the facility failed to ensure a medical screening exam (MSE) was completed for 1 patient (Patient #30) who presented to the ED with complaints of syncope, nausea, and abdominal pain with pregnancy of 30 ED patients reviewed.

The findings include:

Review of Facility A's Policy titled "Transfer Policy-Emergency Medical Treatment and Active Labor Act (EMTALA)" last on 5/31/21 showed "...Patients who come to [facility A] requesting emergency services are entitled to and receive a Medical Screening Examination performed by individuals qualified to perform such examination to determine whether an emergency medical condition exists...Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor... The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or transferred...in general, when an individual...comes to the Emergency Department, and a request is made on the individual's behalf for a medical examination or treatment, the hospital must provide for an appropriate Medical Screening Examination with the capability of the hospital's Emergency Department...to determine whether an emergency medical condition exists...the Medical Screening Examination shall include both a generalized assessment and a focused assessment based on the patient's chief complaint...there should be evidence of this evaluation prior to discharge or transfer..."

Review of the ED central log revealed Patient #30 was listed on the log dated 5/17/2021 at 6:07 PM for syncope/pre-syncope and her disposition was documented as "discharged against medical advice."

Medical record review of Facility A's ED triage record showed Patient #30 arrived at the ED on 5/17/2021 at 6:07 PM with complaints of fainting spells (which started 5/17/2021), nausea and vomiting (since 5/16/2021), and complaints of abdominal pain, and incontinent diarrhea. The patient was 18 weeks and 2 days gestation. Her vital signs were as follows: blood pressure 118/76, temperature 98.6, pulse 127, respirations 16 and oxygen saturation 98% on room air. The patient rated her abdominal pain as a 6 on a scale from 1 to 10, with 10 being the worse pain. Fetal heart tones were obtained and documented at 174. She was triaged using the Emergency Severity Index (ESI) as a 3, indicating urgent but non-emergent needs.

Medical record review of Patient #30's Electrocardiogram (EKG) dated 5/17/2021 at 6:09 PM showed sinus tachycardia at a rate 100 beats per minutes with no acute findings.

Medical record review of ED electronic orders dated 5/17/21 showed the following orders were placed for Patient #30:
6:11 PM initiate IV (intravenous) access
6:12 PM Comprehensive Metabolic Panel (CMP), Ultrasound, Blood Type and Screen, Orthostatic Vital Signs (blood pressure and pulse taken lying down, sitting, and standing), and IV bolus of 1,000 milliliters of Normal Saline.

Medical record review of the ED Physicians Record dated 5/17/2021 showed no documentation a physical assessment or MSE was completed for Patient #30 by the Mid-Level provider in triage or other Qualified Medical Provider (QMP).

Medical record review of the ED Nursing Triage at Facility B dated 5/17/2021 at 9:57 PM showed Patient #30 arrived at the ED with complaints of nausea, vomiting, diarrhea and two syncopal episodes after standing. Her vital signs were as follows: Blood Pressure 105/69, Pulse 81, Respirations 18, and Pulse Oximetry 99%. She rated her pain as a 6. She was triaged using the ESI score of a 3 indicating urgent but non-emergent needs.

Medical record review of an ED Physicians Record at Facility B dated 5/17/21 at 10:13 PM showed a Medical Screening Examination was performed by the physician. Diagnostic testing included a Complete Blood Count (CBC), CMP, and a Urinalysis (UA). The patient received an IV Normal Saline fluid bolus at 10:07 PM. Her discharge diagnoses included orthostatic hypotension and hyperemesis gravidarum (severe nausea and vomiting during pregnancy). She was discharged home in stable condition on 5/18/21 at 12:44 AM.

A review of the facility's video surveillance recording of the ED pedestrian entrance, triage, registration, and ED waiting area on 5/17/21 from 6:03 PM to 8:46 PM showed the following:
6:03 PM- Patient #30 enters ER door, walks up to triage;
6:06 PM- Patient #30 enters triage area, goes for laboratory and radiology testing as ordered by Nurse Practitioner in triage;
7:14 PM- Patient #30 is wheeled into ER waiting area by Radiology staff member with emesis basin in lap;
7:24 PM- Patient #30 leans over in wheelchair (cannot visualize if the patient has eyes open or closed due to camera angle, but patient does remain in wheelchair);
7:25 PM- Patient #30 sits back up in wheelchair;
7:37 PM- Patient #30 moves wheelchair over to an unidentified man in waiting room. Man goes to registration desk points to Patient #30 and talking in direction of registration clerk (unable to visualize clerk);
7:39 PM- Man continues to talk to registration clerk that is not in view;
7:40 PM- Man walks to triage desk, appears to be speaking to someone in triage, pointing to Patient #30. Patient #30 remains in wheelchair in waiting room;
7:41 PM- Male staff member comes out to waiting area and speaks to Patient #30. Staff member goes to triage desk and appears to be speaking with triage staff. Male staff member leaves view (unable to view if he goes into triage or back into the ER due to glare from outside door);
7:42 PM- Patient #30 remains in wheelchair in waiting room;
8:00 PM- Patient #30 remains in wheelchair in waiting room, talking to unidentified male;
8:04 PM- Unidentified male wheels Patient #30 in wheelchair up to registration. Patient #30 appears to be talking to registration clerk that is not in view;
8:07 PM- Patient #30 stops talking with registration clerk, and wheels herself back to the ER waiting area;
8:23 PM- Unidentified male wheels Patient #30 in wheelchair up to triage area;
8:25 PM- Patient #30 wheels up to triage desk and appears to be talking to triage staff not in view;
8:27 PM- Unidentified male wheels Patient #30 back to previous area in waiting room;
8:28 PM- Patient #30 on cell phone in waiting area;
8:44 PM- Unidentified male wheels Patient #30 back to triage desk and appears to be talking with staff behind desk out of view of camera; and
8:46 PM- Unidentified male wheels Patient #30 out of pedestrian ER doors.

During an interview on 6/2/2021 at 11:11 AM, the Risk Manager stated, "...ER [emergency room ] volume was 158 patients which was very high. The Nurse Practitioner [NP] had been asked to work in triage to help expedite triaging patients. She laid eyes on the patient and placed orders, but did not document a medical screening had been completed...."

During a telephone interview on 6/2/2021 at 1:25 PM, NP #1 stated "...when we are really busy, we will have the tech or nurse put in orders to expedite care for the patient...the fetal heart tones of 174 would have been fine for that gestational age for the patient to wait in the lobby, and she would have been classified as urgent, not emergent..." The NP confirmed there was no documentation of a Medical Screening Examination performed.

During an interview on 6/2/2021 at 3:00 PM, the ED Nurse Manager stated "...If they [mid-level provider] see the patient, it would be expected she would document a medical screen..."

During a telephone interview on 6/7/2021 at 11:56 AM, the ED Physician Director stated "...it is the NP role to try to expedite ordering and treatment of the patient. Ideally if it's running the way it's supposed to, they [mid-level providers] can put in orders as they feel appropriate based on their brief assessment of the patient. The quick physical exam in triage should be documented and any assessments that are done..." Continued interview confirmed "...we have made it mandatory now that when they [patients] are seen...they get a note [physician's note]..."

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that a complete medical screening examination was provided for Patient #30 on 5/17/2021 when she presented to the ED with complaints of syncope, nausea, and abdominal pain with pregnancy.