Based on facility policy review, medical record review, facility event report review, observation of a digital video recording, and interviews, the facility failed to ensure care was provided in a safe setting for 1 Emergency Department (ED) patient (#1) of 7 ED patients reviewed. The findings include: During the survey it was found 1 patient (#1) was admitted to the Emergency Department (ED) on 6/15/19 at 6:37 PM for ...CHECK FOR DRUGS AND BIPOLAR... The patient was also having thoughts of Suicidal Ideation (SI) and the facility initiated an involuntary commitment of the patient to a psychiatric facility. While Patient #1 was being held in the ED waiting on an available bed in a psychiatric facility he became combative and attempted to leave the ED. The patient was tased (a pistol shaped weapon which uses an electric current via darts and wires to incapacitate an individual) by a security officer as an intervention to the patient's behavior and to aid the facility in restraining the patient. Patient #1 was not under the custody of local law enforcement at any time while he was in the ED. During a conference in the facility's administration conference room on 8/15/19 at 8:30 AM with the facility's Chief Executive Officer, the facility's Chief Nursing Officer, and the facility's Vice President of Quality, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at Requirement 482.13 Condition of Participation, Patient Rights. The facility's failure to protect Patient #1 from the use of a weapon resulted in Patient #1 being stunned with a taser on 6/16/19. During a conference in the facility's administration conference room on 8/15/19 at 12:30 PM with the facility's Chief Executive Officer, the facility's Chief Nursing Officer, and the facility's Vice President of Quality, the facility presented an Immediate Action Plan for the Immediate Jeopardy which included: 1. The current Use of Force Policy was amended to include the statement ...Weapons include but are not limited to...tasers...Use of weapons by security staff is to be used as law enforcement action only, never in a health care intervention. Weapons are not to be used by hospital staff as a means of subduing a patient in order to place that patient in restraints or seclusion... 2. 100% of Security Officers and ED staff were educated on the changes to the Use of Force Policy. Plans were made for all off duty ED staff to be educated on the policy changes prior to returning to work. 3. A Behavior Emergency Response Team (BERT) was implemented in July 2019, which includes a team of nurses trained in the de-escalation and management of behavioral patients. The team responds to behavioral/psychiatric patients when they begin to show symptoms of violent or other disruptive behavior and interventions are put in place to avoid the escalation of the behaviors. ED staff have been educated on the activation of the BERT team. Security Officers and ED Staff have been educated on the availability, purpose, and use of the BERT team. 4. A Weapons/Use of Force Checklist was developed 8/15/19 to monitor and evaluate the use of any weapons of force on patients. Starting 8/15/19 all incidents involving the use of force or a weapon will be reviewed and evaluated by administration using the check list. 5. 100% of Security staff completed a return demonstration/competency of the steps outlined in the Use of Force Policy. Review of the Immediate Action Plan revealed the immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 8/15/19. The facility remains out of compliance at CFR PART 482.13 Condition of Participation Patient's Rights. Please refer to A-0154.
Based on facility policy review, medical record review, review of a facility event report, review of a digital video recording, and interviews, the facility failed to ensure a weapon was not used as an intervention to restrain 1 patient (#1) of 7 patients reviewed for restraints. The findings include: Review of facility policy titled Patient Rights and Responsibilities, last revised on 9/2018, revealed ...We adopt and affirm the following rights of patients/clients who receive services from our facilities...To receive ethical, high-quality, safe and professional care...To safe and sanitary accommodations...To be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience, or retaliation by staff... Review of facility policy titled Taser [a hand-held pistol shaped weapon that uses an electric current via darts and wires to incapacitate an individual] Use Procedure Policy, last reviewed 6/2017, revealed ...To establish proper procedures for the carrying, use, deployment and aftercare of Taser Devices...Use on Hospital Patients - The only time a taser device shall be used on a patient inside the hospital is when a patient becomes a physical threat to others or himself/herself... Medical review revealed Patient #1 was admitted to the Emergency Department (ED) on 6/15/19 at 6:37 PM for ...Stated Complaint...NEED CHECK FOR DRUGS AND BIPOLAR... Medical record review of a Nurse's Triage Record dated 6/15/19 at 6:43 PM revealed ...PRESENTS HYPERVERBAL [highly verbal]. MANIC [extremely elevated] MOOD. PATIENT IS UNABLE TO PUT A COHESIVE THOUGHT TOGETHER... Medical record review of an ED Physician's Note dated 6/15/19 at 6:50 PM revealed ...Chief Complaint Anxious, Bizarre Behavior, Manic, Suicidal Ideation...Patient brought by parents to the emergency department for possible...psychiatric problems...Patient is currently hyperverbal but will answer direct questions...Patient admits to having thoughts of killing himself with a knife...thoughts of killing everybody else...everyone is trying to kill me... Medical record review of a Nurse's Note dated 6/16/19 at 5:00 AM revealed ...PT [patient] BECAME INCREASINGLY MORE BOISTEROUS AND ANGRY. PT WAS TRYING TO RUN AWAY. NOTIFIED SECURITY TO HELP CALM HIM DOWN. PT BECAME VIOLENT WITH STAFF AND SECURITY. PT WAS GIVEN MULTIPLE CHANCES TO COMPLY AND STOP BEING VIOLENT. PT THEN TRIED TO RUSH OUT THE DOOR TOWARDS OTHER STAFF. SECURITY NOTIFIED PT THAT [Security] WOULD TAZE [tase] HIM IF HE DIDN'T GET BACK IN BED...PT RECEIVED TAZER TO BACK. PT WAS THEN CRAWLING ON THE GROUND AND TRYING TO RUN AWAY. PT STARTED TRYING TO GO INTO OTHER PT ROOMS AND PULLING ON DOOR HANDLES. PT WAS THEN ESCORTED BACK TO HIS ROOM WITH MULTIPLE STAFF AND SECURITY. PT WAS STILL VIOLENT. RESTRAINTS WERE PLACED ON PT PER MD [Medical Doctor] ORDER. PT WAS ALSO GIVEN MEDICATION... Medical record review of a Nurse's Note dated 6/16/19 at 5:10 AM revealed ...PT BECOMING AGITATED AND ATTEMPTING TO RUN OUT OF THE ROOM AND BOLT TOWARDS STAFF MEMBERS. SECURITY AT BEDSIDE AND STATING THAT THEY WILL TAZE HIM IF HE DOES NOT GET IN THE ROOM. MULTIPLE ATTEMPTS FOR PT TO COOPERATE WITH STAFF BEFORE BEING TAZED. STILL UNCOOPERATIVE. SECURITY DELIVERED MULTIPLE TASE TO PT AND PT STILL TRYING TO RUN AWAY. MULTIPLE MALE STAFF MEMBERS CARRIED PT BACK TO ROOM WITH SECURITY FOLLOWING BEHIND. MEDS [medications] ORDERED...GIVEN BY RN [Registered Nurse]. MULTIPLE STAFF MEMBERS TAKEN TO RESTRAIN PT EVEN AFTER MEDS. PT RESTRAINT ORDERS PLACED. PT PUT IN HARD RESTRAINTS [restraints made with a vinyl fabric] AT THIS TIME BY RN... Medical record review of a Physician's Note dated 6/16/19 at 5:11 AM revealed ...Patient became agitated and attempted to run out of the department. Security prior to my intervention taste [tased] the patient at least twice. Patient then physically subdued...given 20 mg [milligrams] of IM [intramuscular injection] Geodon [anti-psychotic medication]... Medical record review of a Physician's Note dated 6/19/19 at 12:15 PM revealed ...Patient did have repeat tele-psychiatry evaluation...After his evaluation, he [psychiatrist] felt the patient was very calm and would be stable for discharge home... Continued review at 12:21 PM revealed ...The patient will be discharged home in stable condition... Medical record review revealed no documentation Patient #1 was placed in the custody of local law enforcement while a patient in the facility. Review of a Risk360 Event Detail Report dated 6/16/19 at 5:05 AM revealed ...Security responded to ER [emergency room ]...to find Pt...in the hall trying to leave. Myself and [another security officer] and a nurse physically escorted him back to the room where he continued to be combative and uncooperative. He was swinging his fists and biting at staff. He struck myself and [other security officer] several times and grabbed ahold of one of the staff by the shirt and hit the staff as well. Since we could not maintain control of the patient physically, I stated that I would Tase him and advised Medical Staff to get a safe distance from the patient. I drew my taser and told the patient that he needed to stay on the bed or he would be tased. He got up and came at me and I kept him back with my free hand and warned him again. He then rushed past me and entered the hall way. At which point I fired my taser in his back. It connected and he fell to the floor. A nurse said they were getting a wheelchair for him and I told him to stay on the ground until the wheelchair arrived or I would use the taser again. He did not comply and I cycled it again and it worked. I advised him again that he needed to stay on the ground, but he got up. Apparently a barb came loose while he was on the floor and it was no longer connected, so nothing happened when I cycled it again. I then fired my second cartridge, but it did not make a full connection. The patient then ran to the end of the hall where he stopped. It appeared he was going to come back to his room, but he instead ran to another patient's room and tried to enter it. My partner [named security officer] drew her taser, but there wasn't a clear shot as medical staff had grabbed ahold of him and were trying to restrain him. I assisted Medical Staff in bringing the patient back to room...he was restrained to the bed and medicated... Review of a video recording dated 6/16/19 at 5:06 AM revealed Patient #1 was in the ED hallway and walking away from security officers and ED staff. Continued review revealed a Security Officer deployed a taser from several feet behind the patient and the patient feel limp to the floor. Further review revealed the patient lay on the ED floor for approximately 45 seconds and then got up and started walking away from Security and ED staff. Continued review revealed the security officer appeared to fire the taser a second time at Patient #1, but there was no visible effect on the patient. Interview with the Security Director on 8/13/19 at 10:00 AM, in the Quality Conference room, confirmed the use of tasers on patients by security officers was an approved action by the facility if the patient was violent or a danger to themselves, other patients, or staff. Telephone interview with RN #1 on 8/14/19 at 7:10 AM revealed the RN remembered Patient #1. Continued interview revealed the patient tried to leave his room and security was called. Further interview revealed the patient became combative and was hitting, kicking, and shouting at the staff. Continued interview revealed a security officer fired a taser, hitting the patient in the back, and the patient fell to the floor for a short time. Further interview revealed the patient got back onto his feet and attempted to leave the ED and the Security Officer attempted to tase the patient again, but the taser did not work. Continued interview revealed Patient #1 was physically held by ED staff and then lifted and carried back to his room by staff and placed in restraints. Further interview confirmed the patient was tased once during the incident. Interview with the Vice President of Quality on 8/12/19 at 3:30 PM, in the Quality Conference Room, confirmed Security Officers used tasers on patients in cases where the patient's safety or the safety of other patients was at risk.
Based on review of facility policy, medical record review, review of a security video recording, and interviews, the facility failed to provide a medical screening examination for one patient (#3) of 25 Emergency Department patients reviewed. Refer to 2406 for failure to provide a medical screening examination.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy reviews, record reviews, observations of video recordings, and interviews, the facility failed to complete an appropriate medical screening exam (MSE) for 1 patient (#3) of 25 Emergency Department (ED) patients reviewed. The findings included: Review of the facility's Medical Screening Examination and Stabilization Policy effective date 2/1/16, revealed, ...hospital must provide an appropriate MSE...The MSE must be completed by an individual (i) qualified to perform such an examination... Review of Patient #3's medical record from Facility A revealed the patient was registered at 10:21 PM on Sunday 9/11/16. Further review of the medical record revealed the patient was triaged at 10:28 PM, and assigned an acuity level of 3 (urgent). Further review revealed the patient presented to the ED with a complaint of ...Just got out of the hospital for pericarditis and this is the same pain and symptoms...Pain in left upper chest to shoulder...moaning in triage...hunched over... Continued review revealed the patient's vital signs at triage were: blood pressure 117/70, Pulse 122, Respiration Rate 20, Oxygen Saturation (O2 Sat) 96% (Oxygen Saturation the amount of oxygen in the blood, normal is 92% or above), and Pain Level was 10 on a scale of 1-10 (1very mild pain and 10 severe pain). Continued review of a triage note at 11:34 PM revealed ...pt [patient] sitting in wheelchair moaning...patient experiencing any pain or discomfort...yes..disposition: waiting room... Medical record review of an Electrocardiogram (EKG a measurement of electrical activity and function of the heart) was performed at 10:26 PM with interpretation of sinus tachycardia and possible left atrial enlargement. Medical record review of Provider Triage form dated 9/11/16 at 10:26 PM revealed the MSE was initiated by a Nurse Practitioner (NP #1), who obtained a history and physical and a physical exam. Continued review at 10:50 PM revealed NP #1 ordered diagnostic laboratory tests and a chest x-ray. Medical record review of the chest x-ray results dated 9/11/16 at 11:18 PM revealed ...overall improved aeration of both lungs. The right sided atelectasis is nearly resolved with small effusion remains...the intr[DIAGNOSES REDACTED]c opacity has also improved...Persistent left basilar atelectasis and small bilateral pleural effusions.... Medical record review revealed no documentation the laboratory tests specimens or the diagnostic tests were completed prior to the patient leaving. Medical record review of an Elopement Note written by NP #1 on 9/11/16, not timed, stated ...This patient left the emergency department or waiting room with no communication to myself, nursing or administrative staff. There was no opportunity to discuss the patient's decision to leave, provide medical advice or discuss alternatives to leaving. The staff has made efforts to locate the patient without success... Medical record review of a nurse's note dated 9/12/16 at 1:04 AM revealed ...Pt left AMA [against medical advice] from WR [waiting room]. No papers signed... Review of the medical record from Facility B revealed Patient #3 (MDS) dated [DATE] at 1:00 AM. Further review of the medical record revealed the patient was triaged at Hospital #2 on 9/12/16 at 1:12 AM with vital signs: Blood Pressure 122/67, Pulse 121, Respirations 16, O2 Sat 99%, and Pain Level 10/10. Further review of the medical record revealed the patient was admitted to Facility B with a diagnosis of [DIAGNOSES REDACTED] Observations of a security video recording of Facility A's ED Waiting room revealed Patient #3 walked into the ED accompanied by an unknown man on 9/11/16 at 10:21 PM and walked directly to the nurses' desk, where she appeared to present for treatment. Further review of the video revealed the following timeline for Patient #3's ED visit on 9/11/16 to 9/12/16: 10:21 PM Patient #3 entered ED and presented at nurses desk. 10:23 PM Patient #3 was taken by a nurse in a wheelchair to triage. 10:32 PM Patient #3 was returned to the waiting room by the nurse and sat in wheelchair in waiting room. 10:55 PM Patient #3 was taken to x-ray by wheelchair. 11:04 PM Patient #3 was returned from x-ray and was left sitting in the wheelchair in the waiting room. 11:38 PM Patient #3 was taken by wheelchair to the registration office. 11:41 PM Patient #3 was taken back to the waiting room in the wheelchair. 12:37 AM Patient #3 was observed walking out of ED waiting room (2 hours and 16 minutes after arrival) with a male and did not return. Telephone interview with NP #1 on 9/27/16 at 8:25 AM on 9/27/16, confirmed Patient #3 left Facility A's ED prior to completion of the MSE. Continued interview confirmed the patient left before the laboratory specimens were obtained and before a re-assessment and a cardiology consult was provided. Telephone interview with RN #1 on 9/26/16 at 3:45 PM confirmed Patient #3 left Facility A's ED on 9/11/16 before the nurse drew the blood specimens for laboratory tests. Continued interview confirmed the laboratory tests were not completed prior to the patient leaving the ED. .
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
An investigation of a possible EMTALA violation (Number TN 862) was initiated on November 19, 2013 and concluded on November 21, 2013. EMTALA investigative guidelines and procedures were followed. As a result of the investigation, deficient practice was identified at 42 CFR489.20(r)(3) and 42 CFR489.24 (r)(c). Prior to the survey, you discovered the violation and implemented corrective action that has been effective over the long term. Therefore, we are not proceeding with a termination of your Medicare provider agreement with the Secretary of Health and Human Services. The administrator was notified on February 20, 2014 by Federal Express overnight mail. A letter and this 2567 were provided. Based on review of the facility's self-reported documentation , Emergency Department (ED) Central Log, medical record review, review of facility policy, and interview, the facility failed to maintain a ED Central log on each individual who presented to the ED for one patient (#27) of twenty-seven patients reviewed. The findings included: Review of facility's self-reported investigation letter dated November 21, 2013, revealed the facility description of the events of an incident which may represent a potential violation of the Emergency Medical Treatment and Labor Act. Review of the letter revealed on November 11, 2013, between 9:00 p.m., and 10:00 p.m., a [AGE] year old child (#27) was brought into the ED by the child's parents, who stated the child injured the arm. Further review revealed the Waiting Room Coordinator (WRC), who was a Registered Nurse (RN), had not worked in the ED before, and this was the first time the RN had worked in the ED. The allegation revealed the WRC RN called the Fast Track RN to inquire about the [AGE] year old child being seen in the Fast Track area. (The Fast Track is a section of the ED where patients with less severe illness/injury are treated.) The Fast Track ED nurse told the WRC the Fast Track section did not screen or examine any patient less than two years old. Continued review revealed the WRC misinterpreted the communication and thought the child was not to be screened or examined at all; and did not refer the child to the regular ED. Further review revealed the WRC told the parent the child could not be seen in the ED. The child's parent filled out a form, and the parent folded the form and put the form in the (named parents) purse and left the ED. Further review revealed the facility watched a video tape recording from the ED and tried to get the tag number on the car but the recording did not reveal the visibility of the car tag. Further review revealed the WRC did not tell the child's parents the facility needed to keep the sign-in sheet for the ED and the facility does not have the child's name or any information. Review of the ED Central Log revealed no documentation of a 22 month child registered in the ED on November 11, 2013, between the hours of 9:00 p.m. and 10:00 p.m. Review of the facility's computer patient record documentation, revealed no medical record for a [AGE] year old child admitted to the ED on November 11, 2013. Medical record review of twenty-six medical records (including two active medical records) revealed each patient had received a medical screening examination by a licensed medical provider and were entered in the ED Central Log. Review of facility policy EMTALA (Emergency Medical Treatment and Labor Act): Tennessee Central Log Policy last reviewed May, 2013, revealed ...the hospital will maintain a Central Log containing information on each individual who comes to DED dedicated emergency department) seeking assistance, whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged ... Review of facility policy EMTALA Central Log last reviewed May 2013, revealed ...emergency room medical records shall contain the following: Identification data, information concerning the time of arrival, means and by whom transported, pertinent history of the injury or illness to include chief compliant and onset of injuries or illness, significant findings, description of laboratory, x-ray and EKG findings, treatment rendered, condition of the patient on discharge or transfer, diagnosis on discharge and instructions given to the patient or his family... Interview on November 21, 2013, at 11:55 a.m., with the ED Director and the ED Clinical Manager, in the ED Clinical Managers Office, confirmed a medical screening was not performed by a licensed medical provider for the patient, no clinical medical record was generated for the patient and the patient was not entered into the ED Central Log. Interview with the Director of Quality Management and the Risk Manager, on November 21, 2013, at 1:10 p.m., in the Risk Managers office, confirmed a medical screening was not performed by a licensed medical provider for the [AGE] year old patient (#27), a medical record was not generated for the patient, and the patient was not entered into the ED Central Log.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of the facility's investigation documentation letter, Emergency Department Central Log, facility documentation, facility policy and procedures, observation and interview, the facility failed to provide a medical screening by a Licensed Medical Professional for one (#27) patient of twenty-seven patients reviewed. The findings included: Review of facility's self-reported investigation letter dated November 21, 2013, revealed the facility description of an incident which may represent a potential violation of the Emergency Medical Treatment and Labor Act. Review of facility's letter dated November 21, 2013, revealed on November 11, 2013, between 9:00 p.m., and 10:00 p.m., a [AGE] year old child was brought into the ED by the child's parents, who stated the child injured the arm. Further review revealed the Waiting Room Coordinator (WRC), who was a Registered Nurse (RN #3), had not worked in the ED before, and this was the first time RN #3 had worked in the ED. The documentation revealed the WRC RN called the Fast Track RN to inquire about the [AGE] year old child being seen in the Fast Track. (The fast track is a section of the ED in which patients with less severe complaints are seen.) The Fast Track ED nurse told the WRC the Fast Track did not screen or examine any patient less than two years old. Continued review revealed the WRC misinterpreted the communication and thought the child was not to be screened or examined at all. Review revealed the WRC RN did not refer the child to the regular ED. Further review revealed the WRC told the parent the child could not be seen in the ED. The child's parent filled out a form (a sign-in sheet) and after being told the child could not be seen, and the parent folded the form and put the form in the parent's purse and left the ED. Review of the ED Central Log revealed no documentation of a 22 month child who was registered in the ED on November 11, 2013, between the hours of 9:00 p.m. and 10:00 p.m. Review of the facility's electronic patient record documentation, revealed no medical record for a [AGE] year old child admitted to the ED on November 11, 2013. Review of facility policy, EMTALA; Definitions and General Requirements, last reviewed May, 2013, revealed ...the hospital with an Emergency Department must provide to any individual, including every infant who is born alive, at any stage of development, who comes to the emergency department, an appropriate Medical Screening Evaluation (MSE) within the capacity of the hospital's emergency department, including ancillary services available to the emergency department, to determine whether or not an emergency medical condition (EMC) exits, regardless of the individual's ability to pay...the EMTALA obligations are triggered when there has been a request for medical care by an individual within a dedicated emergency department (DED), when an individual request emergency medical care on hospital property, other than in a DED, or when a prudent layperson would recognize that an individual on hospital property requires emergency treatment or examination, though no request for treatment is made... Further review revealed ...when a medical screening evaluation is required...an individual MUST receive an MSE within the capabilities of the hospital's DED (dedicated Emergency Department), to determine whether or not an EMC exists...whether or not the treatment requested is explicitly for an emergency condition of (1) the individual comes to a dedicated emergency department of a hospital and a request is made on his or her behalf for examination or treatment for a medical condition... Review of the Rapid Regulatory Compliance (facility computer educational training for all clinical hospital employees) revealed ...2.5: Corporate Compliance: Applicable Laws and Regulations...EMTALA...the Emergency Medical Treatment and Active Labor is commonly known as the Patient Anti-Dumping Statute...this statute requires Medicare hospitals to provide emergency services to all patient...whether or not the patient can pay...hospitals are required to (1) Stabilize patients who may have an emergency condition (2) stabilize patients who have an emergency condition... Review of an electronic mail (Email), dated November 12, 2013, at 9:26 a.m., from the ED Director to the charge nurses for the ED, and to the Nursing Supervisors, revealed ...the WRC is often the first person a patient presenting for treatment sees...it is imperative that they a full and complete understanding of EMTALA...the ED staff are definitely the experts in this area, and need to be the ones staffing the WRC going forward...we have agreed that any licensed ED associate (nurse, EMT-IV, paramedic) may act as the WRC...student techs may not act as the WRC...if we do receive help from a non-ED (named facility) employee, they need to be utilized in the back...if they are familiar with the ED, they may take a zone (just like we always have)...if not, they need to function as a float nurse/tech...they may transport patients, start IV's, give medications, help take patients to the bathroom, reassess pain, etc... Observation on November 20, 2013, at 2:30 p.m., in the ED waiting area, revealed an RN was assigned to the WRC role in the ED. Continued observation revealed the WRC greeted patients upon arrival at the ED, obtained the patients chief complaint and notified the triage nurse of the patient's arrival and chief compliant. Observation on November 21, 2013, at 9:30 a.m., in the ED waiting area, revealed an RN was assigned to the WRC role in the ED. Continued observation revealed the WRC greeted patients upon arrival at the ED, obtained the patients chief complaint and notified the triage nurse of the patient's arrival and chief compliant. Interview on November 20, 2013, at 1:45 p.m., with RN #1, in the Emergency Department Waiting Room, revealed all nurses in the ED rotate and do triage in the ED. Continued interview revealed the nurses have cell phones and once a patient comes into the ED for evaluation, the WRC notifies the triage nurse and the triage nurse will do the triage of the patient. Further interview revealed ...all patients who present to the ED get a medical screening by the physician or the PA... Interview on November 20, 2013, at 1:50 p.m., with ED Physician #1, in the Emergency Department, revealed ...any patient who comes into the ED for treatment will get a medical screening by a licensed healthcare provider...the patients are placed in a room during triage by the nurse... Interview on November 20, 2013, at 3:20 p.m., with the ED Director, in the ED Director office, revealed ...was called by the ED staff and told a 22 month child had presented to the ED with the parents due to an arm injury...the child had not been seen the ED and the child and parents had left the ED without being seen by a licensed medical provider... Further interview revealed ...the child's parent put the sign-in sheet in the parents purse and we did not get any demographical information so we don't know who the child was...we do not have a medical record on the patient... Further interview revealed the facility reviewed the ED video recordings and was unable to get a car tag number or identify the child or the child's parents. Further interview revealed ...I told the staff to document the findings and the next morning the Quality Manager and Risk Manager was notified by me...I notified the CNO (Chief Nursing Officer) and the Assistant CNO... Further interview revealed ...after talking with CNO...I sent an email to the ED staff and the nursing supervisors...we immediately implemented a policy where no float pool nurses will be assigned to the WRC role in the ED... Telephone interview with RN #3, on November 20, 2013, at 3:40 p.m., revealed the nurse was a float pool nurse who was assigned to the ED on November 11, 2013. Continued interview revealed I had never worked the ED before...this was the first time I had ever worked in the ED...had never triaged before so they assigned me to the waiting room...they told me all I had to do was stamp the sign-in sheet and call the RN and tell them what was wrong with the patient... Further interview revealed RN #3 did not have access to the ED computer system. Continued interview revealed ...a [AGE] year old was brought in by the parents who stated the child had an arm injury and they wanted to get the child evaluated... Further interview revealed ...I stamped the triage sign-in sheet like they told me to...I spoke with (named nurse, RN #4) who was working the Fast Track, and the nurse told me the child could not be seen in the Fast Track due to the extent of the injury and the Fast Track PA said the child could not be seen in the Fast Track area...the nurse hung the phone up... Further interview revealed ... the RN never told me the ED had two different areas and the child should be taken to the main ED... Continued interview revealed ...I told the (child's parent) the child could not be seen in the ED and the child's parent stated they had never heard of that... Further interview revealed ...the child's parent put the sign-in sheet in the parent's purse and left the ED with the child... Further interview revealed ...RN #4 called me about an hour later and asked me where the child was at...I told RN #4 the child and the parents had left the ED after I told them the child could not be seen in the ED...RN #4 explained to me the process related to Fast Track and the main ED and told me the child should have been triaged and evaluated in the main ED... Continued interview revealed the RN #3 had completed the hospital required EMTALA training for hospital employees but had not received the ED required EMTALA training. Further interview with RN #3 confirmed the child was never seen by the nurse or a licensed healthcare provider, and therefore a medical screen was not performed. Telephone interview on November 20, 2013, at 4:10 p.m., with RN #4, revealed the RN was working from 7 PM to 11 PM in the Fast Track section in the Emergency Department on November 11, 2013 (the night of the incident). Continued interview revealed the RN worked in the ED and ED triage area. Further interview revealed the nurse (RN #3) was a float pool nurse that was assigned to the ED...RN #3 did not have access to the EDM (ED computer documentation)...the day shift triage nurse had told RN #3 when a patient came into the ED...get the name and why they are here and then call the triage nurse... Continued interview revealed ...the WRC called me in the Fast Track area and told me about the patient...I told the nurse we did not see [AGE] year old patients in the Fast Track and due to the child's compliant...the fast track would not be the appropriate area for the child... Continued interview revealed ...I talked to (RN #3) in great detail about the different areas in the ED and told the nurse why the child would not be seen in the Fast Track department...I instructed the nurse to call the triage nurse...the physician assistant (PA) assigned to the Fast Track was sitting right beside me and heard me talking and giving instructions to the nurse (RN #3)... Continued interview revealed ...about an hour later I checked the ED tracking board to see where the child went to and noticed a [AGE] year old was not on the tracking board...this seemed odd to me due to nature of the child's complaint ... Continued interview revealed ...I called the WRC and asked where the child was...the nurse told me the patient had left the ED with the parents and the nurse (RN #3) had told the parents we would not see the patient...RN #3 did not call the triage nurse... Further interview revealed ...maybe I should have been clearer about the two departments in the ED... Continued interview revealed ...I called the charge nurse (RN #5)...and told the charge nurse what had happened and this was a potential EMTALA violation...the charge nurse talked to the WRC and RN #3 told the charge nurse the patient and family had left the ED...the parent had put the sign-in form on the parents purse and a chart was never generated for the child...we did not have any demographical information... Continued interview revealed ...we called the ED Director at home about the patient leaving... Further interview revealed float pool nurses usually are oriented to the ED and have access to the EDM... Continued interview revealed RN #4 had completed the required hospital and ED EMTALA training. Telephone interview on November 20, 2013, at 4:40 p.m., with RN #5, revealed the RN was working the night shift, as the charge nurse, on November 11, 2013 (the night of the allegation). Continued interview revealed the RN (RN #5) had made the assignments in the ED the night of November 11, 2013 and had assigned RN #3 as the WRC. Further interview revealed ...the nurse was assigned as the WRC because the nurse had never worked in the ED...I told the nurse (RN #3) if a patient came into the ED that needed immediate attention to call the me or the triage nurse...the nurse (RN #3) did not tell me the nurse did not have access to the EDM computer system... Continued interview revealed ...RN #4 called me and asked me to come over to the Fast Track area...when I went over there RN #4 explained to me what had happened...I went out to ED waiting room and talked to RN #3... Continued interview revealed ...RN #3 told me the Fast Track nurse had told the nurse the patient could not be seen in the Fast Track and RN #3 had told the patient parent the patient could not be seen...I explained to the RN (#3) the seriousness of the situation and explained the Fast Track and triage system to the nurse... Further interview revealed the charge nurse went back into the ED...called the nursing supervisor and told the nursing supervisor what had happened...shortly after the nurse (RN #3) was assigned to another area in hospital and did not continue to work as the WRC... Continued interview revealed ...normally we would just work short and reassign duties if the WRC position was not filled during the shift... Further interview confirmed the patient was medically screened in the ED. Continued interview revealed RN #5 had completed the required hospital and ED training for EMTALA. Interview on November 21, 2013, at 9:20 a.m., with the WRC, in the ED waiting room, revealed the WRC role is to meet and greet the patients, enter the patient data into the system and assure the patients get to the appropriate area in the ED. Continued interview revealed ...if a patient comes in with immediate needs...call the triage nurse or the charge nurse... Continued interview revealed ...the patient enters the Social Security Number into the keypad...we fill the computer screen out regarding the patient's complaint and give the information to the triage nurse... Telephone interview on November 21, 2013, at 11:30 a.m., with the Medical Director of the Emergency Department, in the conference room, revealed ...all patients who present to the ED should receive a medical screening by a licensed medical provider... Further interview revealed ...the patient in question did not see the physician or the PA... Interview on November 21, 2013, at 11:55 a.m., with the ED Director and the ED Clinical Manager, in the ED Clinical Managers Office, confirmed a medical screening was not performed by a licensed medical provider for patient #27 and no clinical medical record was generated for the patient. Interview on November 21, 2013, at 12:20 a.m., with the Assistant CNO (ACNO), in the ACNO office, revealed ...we typically do not assign the float pool nurses to the ED... Further interview revealed all patients who come into the ED should receive a medical screening by a licensed medical provider. Continued interview revealed ...on November 12, 2013, we implemented a policy where no float pool nurses will assigned as the WRC...the email was sent by the ED Director to the ED staff, Nursing Supervisors and all administration... Interview with the Director of Quality Management and the Risk Manager, on November 21, 2013, at 1:10 p.m., in the Risk Managers office, confirmed a medical screening was not performed by a licensed medical provider for the [AGE] year old patient (#27) and a medical record was not generated for the patient. Plan of Correction Submitted on 11/21/13 by Quality Director: 1. Immediately (11/12/13) , eliminated the use of Float Pool staff as ED WRC's. (Waiting Room Coordinator) ED charge nurses were notified per e-mail by the ED director about the immediate staffing change for the WRC position. Charge nurses were asked to sign acknowledgement/roster after reading . Goal is to have 100% of CN's complete this review by 11/22 or at time of their next scheduled shift. (if after 11/22). WRC assignment will be tracked per manual log. Expectation that this will be completed by ED licensed staff when they are in the WRC role. ED Director and/or designee will be responsible for monitoring assignment log on a weekly basis. 2. Nursing (House) Supervisors were also notified of the discontinuation of using float staff in the WRC role in the ED. This communication ws sent on 11/12/13 by the ACNO in the form of an email. Supervisors were requested tp sign the acknowledgement form/roster fter review. Goal is to have 100% of supervisors cmplete this review by 11/22 or at a time f their next scheduled shift. The ED Director Cnd Chief of Nursing are responsible parties and this will be ompleted by 11/22/13. 3. EMTALA refresher education provided to the ED as of 11/20/13. The ED Director developed refresher education. Topics covered included the MSE requirement, WRC role and overview of government citations and penalties. This education was provided in a self study packet. Expectation is that this will be completed by 11/27/13; all ED staff are requested to complete roster sheet as an acknowledgement of receipt of this information. If staff is not scheduled for work and/or on LOA, they will need to complete this training by the completion of theri next scheduled shift. 4. Annual EMTALA education (approx one hour) is required by all ED licensed staff as well as with Nursing Supervisors. Education reviews all aspects of EMTALA oblications and various modules are followed by written exams. (80% is passing score) This same education is part of the ED orientation process also. The yearly education is required to be completed by 12/31/13. The individuals who were on duty on the day in question have completed this specific EMTALA course for year 2013. The ED Director is responsible for alll Education and the final completion date is 12/31/13. 5. The ED Director created a quick reference sheet of WRC roles/responsibilities and posted them at the WRC desk. The responsibilities are covered in the annual ED licensed staff competencies currently. The ED Director is responsible and the annual ocmpetencies will be completed by 12/31/13. 6. House-wide education EMTALA (focusing on presentation for treatment of medical condition and hospitals obligation) will be provided in December through the hospital education self-study packet distribution. This will be for designated clinical areas. An attendance/completion roster will be used to track compliance/completion of this training. It should also be noted that EMTALA is also covered in annual Healthstream required training-Clinical Rapid Regulations. This training is required to be completed by 12/31/13 and the Director of Hospital Education will be responsible.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and interview, the facility failed to ensure respiratory therapy followed physician's orders for one (#2) of five patients reviewed. The findings included: Medical record review revealed patient #2 was admitted to the facility on on [DATE], with complaints of weakness, decreased activity, and foul smelling urine. Continued medical record review revealed the patient had a past medical history which included Frequent Urinary Tract Infections, Depression, Chronic Obstructive Pulmonary Disease, Chronic Pain, Dementia, Hypertension, and Chronic Foley Catheter. Further review revealed the patient was treated and discharged to a skilled nursing facility on August 9, 2011. Review of physician's orders dated August 3, 2011, revealed Percussion vest TID (three times daily) for 20 minutes with respiratory treatment. Continued review of physician's orders dated August 6, 2011, revealed Albuterol Sulfate 0.63 mg inhalation nebulizer treatment QID (four times daily) with home percussion vest. Review of respiratory notes dated August 6, 2011, revealed Patient took off vest before time was up. Continued review of respiratory notes dated August 7, 2011, at 2:00 p.m., revealed Could not locate vest portion of vest airway clearance machine. Further review of respiratory therapy notes dated August 7, 2011, at 7:00 p.m., revealed Used flutter valve in place of missing vest. Continued review of respiratory notes dated August 8, 2011, revealed Patient has vest machine in room but there is no vest. Further review of respiratory notes revealed no documentation the percussion vest was used from the time of the initial order on August 3, 2011 until documentation on August 6, 2011 stating the patient was not cooperative with use of the vest. Review of physician's progress notes dated August 8, 2011, revealed ...daughter complained that vest was not being used.... Interview with the Risk Manager on September 21, 2011, at 3:30 p.m., in the conference room, revealed it had been reported to the department the vest was missing. Continued interview revealed the room was searched to no avail and the laundry, which is off-site, was called but had not found anything in the linen. Further interview revealed Respiratory Therapy was assisting the daughter to replace the vest. Continued interview revealed the vest was replaced the next day (August 9, 2011). Further interview confirmed the patient was ordered to have respiratory treatments with the percussion vest on August 3, 2011, and there is no documentation the vest was utilized until August 6, 2011, when a second order for its use was written.
Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to comply with the responsibilities of Medicare Hospitals in emergency cases for one patient (#2) of twenty six patients reviewed. The findings included: Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had drank a water bottle of antifreeze yesterday. Review of the ED physician's (MD #1) emergency room Report, dated July 9, 2011, revealed the patient's family was informed of the ...potential lethality ... of the patient's condition. Review fo the ED Physician's notes also revealed, Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency and Disposition ...Transferred to ...Medical Center. Condition: Critical but stable. Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, out of Network Amerigroup. The medical benefits documented on the Transfer form were, In Network Facility. Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m. Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, ...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here. Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, You want to transfer...for higher level care..., and MD #1 answer to the Access Center staff was, No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis. Access Center staff then asked, Do you guys do that? and MD #1 stated, Yep, this is purely insurance. Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, ...I would admit...here, but...is out of our insurance network, so I've got to transfer. Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, the patient was potentially dangerously ill and needed admission to an ICU. MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, ...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people. MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, no response or preference in any manner regarding...care or transfer. MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU). Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, Summit did not take...insurance and we would have to be transferred to... PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were simply told...did not take...insurance and...would have to be transferred. Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented. Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called out of network. The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization , are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1. Review of the facility's policy titled, EMTALA-Transfer Policy last review date May 2010, revealed, The transfer of an individual shall not be predicated upon...economic status. The policy also states, The request must be in writing and indicate the reasons for the request... Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011. Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties. C/O # TN .
Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to assure that patient (#2) of twenty six patients was appropriately stabilized prior to transfer. The findings included: Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had drank a water bottle of antifreeze yesterday. Review of the ED physician's (MD #1) emergency room Report, dated July 9, 2011, revealed the patient's family was informed of the ...potential lethality ... of the patient's condition. Review of the ED Physician's notes also revealed, Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency and Disposition ...Transferred to ...Medical Center. Condition: Critical but stable. Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, out of Network Amerigroup. The medical benefits documented on the Transfer form were, In Network Facility. Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m. Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, ...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here. Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, You want to transfer...for higher level care..., and MD #1 answer to the Access Center staff was, No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis. Access Center staff then asked, Do you guys do that? and MD #1 stated, Yep, this is purely insurance. Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, ...I would admit...here, but...is out of our insurance network, so I've got to transfer. Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, the patient was potentially dangerously ill and needed admission to an ICU. MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, ...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people. MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, no response or preference in any manner regarding...care or transfer. MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU). Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, Summit did not take...insurance and we would have to be transferred to... PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were simply told...did not take...insurance and...would have to be transferred. Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented. Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called out of network. The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization , are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1. Review of the facility's policy titled, EMTALA-Transfer Policy last review date May 2010, revealed, The transfer of an individual shall not be predicated upon...economic status. The policy also states, The request must be in writing and indicate the reasons for the request... Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011. Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties. C/O # TN .
Based on medical record review, review of transcripts of recorded conversations between physicians, interviews, policy reviews, review of hospital census records, and review of on call schedules, the facility failed to appropriately transfer one patient (#2) of twenty six patients reviewed. The findings included: Review of Medical Records from Hospital #1 revealed Patient #2 presented to the Emergency Department (ED) at Hospital #1 on July 9, 2011, at 10:23 p.m., for complaint of drug overdose and suicide attempt. Review of the Emergency Patient Record revealed the patient had drank a water bottle of antifreeze yesterday. Review of the ED physician's (MD #1) emergency room Report, dated July 9, 2011, revealed the patient's family was informed of the ...potential lethality ... of the patient's condition. Review fo the ED Physician's notes also revealed, Clinical Impression ...Intentional overdose with ethylene glycol, with resulting metabolic acidosis and acute renal insufficiency and Disposition ...Transferred to ...Medical Center. Condition: Critical but stable. Further review of the Medical Record at Hospital #1 revealed no documentation of Patient #2 requesting transfer to another facility. Review of the EMTALA Memorandum of Transfer form revealed no documentation of the patient requesting transfer to another facility. The reason for transfer documented on the EMTALA Memorandum of Transfer form was, out of Network Amerigroup. The medical benefits documented on the Transfer form were, In Network Facility. Review of Medical Records from Hospital #2 revealed Patient #2 was admitted to the Medical Intensive Care Unit (MICU) at Hospital #2, on July 10, 2011, at 3:21 a.m. with diagnoses of Ethylene Glycol Poisoning, Metabolic Acidosis, Acute Kidney Injury, Depressive Disorder, Suicide Attempt, and Bipolar Disorder. Review of a Progress note dated July 11, 2011, revealed the patient was medically stable and was committed to a psychiatric facility on July 11, 2011, at 4:00 p.m. Review of the transcript of a conversation recorded on July 10, 2011, at 1:33 a.m., between MD #1 and the Access Center staff at Hospital #2 discussing the transfer of Patient #2 to Hospital #2, revealed MD #1 stated, ...has an emergency medical condition, and her insurance is out of our network. Otherwise I'd admit...here. Further review of the July 10, 2011, transcripts, on page 10, revealed at 2:01 a.m. Access Center staff asked MD #1, You want to transfer...for higher level care..., and MD #1 answer to the Access Center staff was, No, because...out of our insurance network...otherwise we could care for here, but may well need dialysis. Access Center staff then asked, Do you guys do that? and MD #1 stated, Yep, this is purely insurance. Further review of the July 10, 2011, transcripts revealed, on page 12, a recorded conversation between MD #1 and MD #2 (Physician on-call at Hospital #2), in which MD #1 stated, ...I would admit...here, but...is out of our insurance network, so I've got to transfer. Interview with MD #1, by telephone, on July 19, 2011, at 2:00 p.m. revealed MD #1 remembered transferring Patient #2 on July 10, 2011. MD #1 stated, the patient was potentially dangerously ill and needed admission to an ICU. MD #1 also stated Patient #2 could have been treated at Hospital #1, but was transferred to Hospital #2 because, ...was out of our network. This patient had Amerigroup Tenncare which is out of our network which means we have to transfer these people. MD #1 also stated he notified the patient regarding...out of network status and explained Hospital #1 did not accept the patient's insurance. MD #1 stated Patient #2 was depressed and uninterested in care, and did not respond when the transfer was discussed. MD #1 stated the patient had, no response or preference in any manner regarding...care or transfer. MD #1 stated the patient's grandparents were present when the transfer was discussed. MD #1 stated the patient was stable enough for transfer but needed admission to an Intensive Care Unit (ICU). Interview with Patient #2's grandmother (PGM), by telephone, on July 21, 2010, at 9:45 a.m., revealed PGM was present in the ED at Hospital #1 on July 9, 2011, and remembered the conversation regarding transfer from Hospital #1 to Hospital #2. PGM stated the patient and family were told, Summit did not take...insurance and we would have to be transferred to... PGM stated the patient did not request a transfer and the family present did not request a transfer. PGM stated they were simply told...did not take...insurance and...would have to be transferred. Interview with the Emergency Department Director, in the ED Employees Lounge, on July 20, 2011, at 11:00 a.m. confirmed there was no documentation of Patient #2 requesting to be transferred in the medical records for the July 9, 2011, ED visit. The ED Director confirmed it was the facility's policy to document the patient's request for transfer on the EMTALA Memorandum of Transfer form, and confirmed that Patient #2's request was not documented. Interview with the Director of Case Management (DCM), on July 19, 2011, at 1:45 p.m. revealed Hospital #1 is not part of the Tenncare Amerigroup network which meant they do not recieve payment from this insurance network. The DCM stated patient's with Amerigroup insurance, are called out of network. The DCM stated there were no written policies for handling out of network patients, but the facility followed instruction given by the insurance company. The DCM stated out of network patients recieve a Medical Screening Exam, and stabilizing treatment. The DCM stated stable out of network patients, that need additional treatment or hospitalization , are educated on the fact Hospital #1 does not accept their insurance, and the patient is given the choice of transfer to another hospital, or admission to Hospital #1. Review of the facility's policy titled, EMTALA-Transfer Policy last review date May 2010, revealed, The transfer of an individual shall not be predicated upon...economic status. The policy also states, The request must be in writing and indicate the reasons for the request... Review of the Midnight Daily Census report for July 9, 2011, revealed Hospital #1 had six (6) Medical Intensive Care Unit Beds available on July 9, 2011. Review of the Daily Call Schedule for July 9, 2011, revealed Hospital #1 had physician's on call for Internal Medicine, Urology, and Psychiatry specialties. C/O # TN .
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