Tristar Summit Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 32792 Based on review of the facility’s Medical Staff Bylaws, review of facility policies, review of medical records, review of facility video footage, and interviews the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) and stabilizing treatment within its capabilities for one (Patient #8) of 8 pediatric patients reviewed. The findings included: Patient #8 presented to the Emergency Department (ED) on 9/27/2023 at 10:12 AM via private vehicle with complaints of “Fall from monkey bars, can’t stand. Denies LOC [Loss of Consciousness]” with a chief complaint of “Hip/Pelvis” from a fall occurred 2 days earlier. Patient #8 was 9 years old and accompanied by her mother. She presented to Triage in a wheelchair. Her mother reported she complained of lower back pain and an inability to walk. X-Rays of the Lumbar, Thoracis, and Pelvis were completed. She received Ibuprofen 200 mg for pain rated at an “8” out of 10 pain scale with 10 being the worst pain imaginable. She was discharged from the ED on 9 /27/2023 at 12:11 AM with diagnosis of Contusion of Back, Acute Lumbar Myofascial Strain, and Strain of Thoracic Back Region and was instructed to follow-up with her physician in two days and to return to the ED as needed. The ED failed to provide a Computerized Tomography (CT), a urinalysis to determine possible kidney damage from a fall to the back, and a detailed neurological examination. Cross Refer to A-2406”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination 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 exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 32792 Based on review of the facility’s Medical Staff Bylaws, review of facility policies, review of medical records, review of facility video footage, and interviews the facility failed to provide an appropriate Medical Screening Examination (MSE) and treatment within its capabilities for one (Patient #8) of 8 pediatric patients reviewed. The findings included: Review of the facility’s Medical Staff Bylaws, dated 12/13/2022, revealed “...a complete medical history and physical examination must be performed and documented in the patient’s medical record...the scope of the medical history and physical examination will include...review of systems...neuromuscular...physical examination, to include pertinent findings in those organ systems relevant to the presenting illness...” Review of the facility policy “Tennessee EMTALA [Emergency Medical Treatment and Labor Act] - Medical Screening Examination and Stabilization Policy”, dated 11/2023, revealed “...The MSE [Medical Screening Examination] must be appropriate to the individual’s presenting signs and symptoms and the capability...of the hospital...an on-going process...” Medical record review revealed Patient #8 (9-years-old) entered the ED on 9/27/2023 at 10:12 AM, with her mother via private vehicle, with a stated complaint of “Fall from monkey bars, can’t stand. Denies LOC [loss of consciousness] and a chief complaint of Hip/Pelvis”. Continued review revealed she entered the emergency department (ED) in a wheelchair. Her acuity was assessed as ESI (Emergency Severity Index) Level 3 “urgent, priority 3” indicating care was needed within 15 minutes. Further review revealed Patient #8 had fallen off monkey bars two days earlier and landed on her back. She denied loss of consciousness but complained of lower back pain and inability to walk. Her mother had given her Motrin (nonsteroidal anti-inflammatory pain medication). The reason for the ED visit was listed as back/hip pain with her pain intensity was listed as “8 - severe pain”. Medical record review revealed Patient #8 was evaluated by Physician Assistant (PA) #1 on 9/27/2023 at 10:19 AM with a review of systems, physical examination, and medications. Continued review revealed since the fall 2 days earlier, Patient #8 had complained of back pain and refused to walk due to pain. She was able to crawl but would not stand. Further review revealed her pain had increased on 9/27/2023 and she had developed diarrhea. The Review of Systems revealed she reported diarrhea, back pain, and difficulty walking. A review of her focused physical examination revealed she had full range of motion with no midline vertebral tenderness. The assessment of the back revealed flank/spine/paraspinal showed thoracis paraspinal tenderness, thoracis spine tender, lumbar paraspinal tenderness, and lumbar spine tenderness. Assessment of the lower extremity showed the right and left hip with tenderness present. Patient #8 skin assessment revealed abrasions “...scattered T/L [thoracis/lumbar] spine regions...” The PA’s note revealed “...observed to crawl onto ED bed without difficulty...” Gait abnormality was documented as Antalgic (Abnormal pattern of walking secondary to pain) Gait. Medical record review revealed Patient #8 received Ibuprofen 200 milligrams at 10:35 AM for her pain rated as an 8 out of 10. Medical record review revealed orders for X-Rays of the lumbar spine, three views, X-Rays of the Thoracis Spine, three views, and X-Ray of the Pelvis, two views. The X-Rays revealed no fractures, malalignment, or osseous (bone) abnormalities. Medical record review of the re-evaluation from PA #1, dated 9/27/2023 at 11:57 AM, showed documentation of the X-Ray results, no sign of neurologic deficit on the physical exam “...suspect back contusion with thoracis and lumbar strain. Will provide Ibuprofen, Tylenol to alternate for pain control. Instructed to follow-up closely with pediatric orthopedist if symptoms do not improve...”. Further review revealed Patient #8 was discharged home on 9/27/2023 at 12:11 PM with a diagnosis of Contusion of Back in Improved Condition. The secondary diagnosis was Acute Lumbar Myofascial (long term pain condition with muscle involvement and the thin cover of tissue that hold the muscles in place) Strain and Strain of Thoracis Back. The ED documented she was in improved condition. Medical record review revealed no re-assessment of Patient #8’s pain level after the administration of the Ibuprofen. Further review revealed no physician orders for Computerized Tomography (CT) to determine the location or cause of her inability to walk and ongoing pain. Continued review revealed no order for a urinalysis to rule out kidney damage related to the fall. Review revealed the back/spinal/neuro examination did not include detailed documentation of motor examination, sensory examination, coordination, reflexes, or gait. There was no documentation Patient #8 demonstrated an ability to ambulate. Review of the video footage dated 9/27/2023 beginning at 10:20 AM, revealed Patient #8 was assisted from the wheelchair to the ED bed. Patient #8 was observed on her knees and crawled up to the head of the bed. Continued review revealed Patient #8 straightened her legs and later crossed her legs. Further review revealed PA #1 laid the head of the bed flat and assisted Patient #8 on her left side; then manually palpated her spinal column. Patient #8 returned to her back without assistance. Further review revealed Registered Nurse (RN) #2 administer Ibuprofen to Patient #8 at 10:35 AM. An X-Ray student arrived with a wheelchair to transport Patient #8 at 10:44 AM. Observation of the footage revealed Patient #8 pivoted to the end of the bed and the mother picked her up and placed her in the wheelchair. When Patient #8 returned from the Radiology Department at 11:04 AM, the mother assisted Patient #8 back to the ED bed with Patient #8’s left leg briefly on the foot pedal before she crawled up into the bed. At 12:21 PM, RN #2 returned to the room with discharge instructions and a wheelchair. The mother pulled up Patient #8 by both arms while she pivoted to the side of the bed, placed both feet briefly on the floor, and placed her in the wheelchair. An observation of the outdoor visitor ED canopy area, at 12:28 PM, the mother assisted Patient #8 into the car. Patient #8 placed both feet on the ground, although both knees were bent, while the mother supported her. She bent her left leg, then the right, and pivoted into her car seat. During a telephone interview on 1/2/2024 at 12:23 PM, PA #1 stated Patient #9’s mother was concerned because of the pain and not walking for 2 days. She stated she watched her ambulate to the restroom and had no focal weakness except for pain “...she had pain upon palpation of both hips, no signs of deformity or no signs or symptoms of neuro deficits...I remember she was able to crawl unto the ED stretcher...”. She stated her X-Rays were negative for bony injury and she recommended follow-up with a pediatric orthopedist if the pain continued. During a telephone interview on 1/2/2024 at 1:30 PM, RN #2 stated she triaged Patient #8. She went into Patient #8’s ED room to make sure the ED placement was appropriate (she was placed in the Fast Track area of the ED). She stated she observed Patient #8 stand from the wheelchair to the bed and crawled into the bed “...she stood up, hands onto the bed and crawled on her hands and knees...”. She stated PA #1 was at the bedside and wanted to see if Patient #8 was able to stand or if her legs just hurt when she was standing. During a telephone interview on 1/2/2024 at 3:11 PM, ED Physician #4 stated Patient #8’s X-Rays were read as normal with normal spinal findings. When asked about Patient #8 not walking, he said “...if can’t weight bear...should be admitted...the injury doesn’t match the reporting of not walking...” In a separate telephone interview on 1/2/2024 at 3:45 PM, Physician #4 stated a pain response would cause pain if Patient #8 had a L4 (Lumbar) compression fracture. During an interview on 1/3/2024 at 11:15 AM, RN #3 stated she was Patient #8’s ED nurse. She stated she observed her crawl onto the bed and was able to move her legs. She stated she administered the Ibuprofen for pain. She asked Patient #8 to describe her pain as “...no pain to chewing your arm off on a scale from 1 to 10...” with Patient #8 rated her pain as ‘8’.”