Based on review of medical staff rules and regulations, review of facility policies, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 3 patients (#36, #37, and #40) of 40 Emergency Department (ED) patients reviewed. Refer to A-2406 for failure to provide a medical screening examination.

Based on review of medical staff rules and regulations, review of facility policies, review of Tennessee Code Annotated 63-7-103 (Tennessee Practice of Professional Nursing), medical record reviews, and interviews, the facility failed to provide a Medical Screening Examination (MSE) by a Qualified Medical Provider (QMP) for 3 patients (#36, #37, and #40) of 33 Emergency Department (ED) patients reviewed. The findings included: Review of the facility's "...Medical Staff Rules and Regulations..." revised September 2015, revealed "...The screening of individuals seeking emergency medical care in the Emergency Department for the purposes of determining whether the individual has an emergency medical condition that requires stabilizing treatment, shall be done by the Emergency Department physician, or by an appropriately credentialed Physician Assistant and/or Nurse Practitioner working within the practitioner's approved scope of practice under the supervision of an Emergency Department physician. In the case of pregnant patients in possible labor, the medical screening examination shall be done by registered nurses with special competence in obstetrics in consultation with an obstetrician..." Review of facility policy "...Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines..." last revised 7/2017, revealed "...A Medical Screening Examination (MSE) will be performed for any individual that...presents on hospital property and requests examination or requires treatment for what may be an emergency medical condition...Medical screening examinations are provided regardless of diagnosis...If a Non-physician QMP [Qualified Medical Provider] determines a woman is in false labor, a physician must certify the diagnosis by telephone consultation or by actually examining the patient..." Review of facility policy "...Medical Screening Examination of the Obstetric Patient..." last reviewed 7/0216, revealed "...Qualified Obstetrical Evaluator as defined by the OB Medical Staff...A registered nurse with a minimum of 2 years experience as an Obstetrical Nurses or equivalent hospital approved in writing by the chairman of the OB Dept [department] to evaluate obstetrical patients in the absence of the immediate attendance of a licensed physician..." Review of the Tennessee Code Annotated 63-7-103 "...Title 63 Professions of the Healing Arts...Nursing...General Provisions..." dated 2016, revealed "...professional nursing includes...(A) Responsible supervision of a patient...(B) Promotion, restoration and maintenance of health or prevention of illness of others...(C) Counseling, managing, supervising and teaching of others...(D) Administration of medications and treatments as prescribed by a licensed physician...or nurse authorized to prescribe...(E) Application of such nursing procedures as involve understanding of cause and effect...(F) Nursing management of illness, injury or infirmity...(b) the practice of professional nursing does not include acts of medical diagnosis or the development of a medical plan or care..." Continued review did not specify Registered Nurses (RN) were permitted to complete Medical Screening Examinations under the Tennessee Nurse Practice Act. Medical record review of an Emergency Department (ED) Triage note revealed Patient #36 arrived in the ED at Hospital B on 7/31/18 at 11:04 PM for complaint of (c/o) "...39 weeks pregnant with vaginal bleeding..." Continued review revealed no documentation a MSE was completed in the ED, but was transferred to the OB department at 11:16 PM. Medical record review of the OB Triage documentation dated 7/31/18 at 11:16 pm revealed Patient #36 was admitted to Obstetric (OB) department. Further review revealed the patient was assessed by a Registered Nurse (RN) on 7/31/18 at 11:37 PM and on 8/1/18 at 12:49 AM. Continued review on 8/1/18 at 1:16 AM revealed "...[physician] Called and updated on pts [patients] arrival, c/o vaginal bleeding; SVE [sterile vaginal exam] 1.5 [centimeters] [dilatation]...60 [%] [effacement-thinning of cervix]...station -3 [fetal station-position of baby] with scant brown bleeding noted on glove. Ctx [contraction] q [every] 5-8 minutes...Ok to dc [discharge] home..." Further review revealed the patient was discharged home on 8/1/18 at 1:33 AM. Continued review revealed no documentation Patient #36 received a MSE by any provider other than a RN. Medical record review of the OB Triage documentation revealed Patient #37 was admitted to OB Triage at Hospital B on 7/9/18 at 12:26 PM for c/o of "...EGA [estimated gestational age] 38.3 [38 weeks and 3 days]...abd [abdominal] pain since yesterday evening..." Continued review at 12:32 PM revealed the patient was assessed by a RN and "...dilatation 0.5 [centimeters]...effacement 50...station -3..." Continued review at 1:40 PM revealed "...[physician] notified of the pts C/O HX [complaint and history], Reactive FHR [fetal heart rate] VS [vital signs] VE [vaginal exam] pt vagaled [heart rate slowed] on her back and felt better when turned on her side...Pt is in touch with her OB...is going to follow up with him..." Further review revealed the patient was discharged at 2:00 PM. Continued review revealed no documentation Patient #37 received a MSE by any provider other than a RN. Medical record review of the OB Triage documentation revealed Patient #40 was admitted to OB Triage at Hospital B on 12/3/18 at 11:41 PM for EGA 38.7 and c/o "...contractions worsening..." Continued review at 11:55 PM revealed "...Cervix Dilation 3...Effacement 50...Station -3..." Further review revealed on 12/4/18 at 1:00 AM revealed "...Uterine Contraction Frequency [every] 3-6 [minutes]..." Continued review revealed the patient was discharged on [DATE] 1:10 AM. Further review revealed no documentation Patient # 40 received a MSE by any provider other than a RN. Interview with RN #1 at Hospital B on 12/11/18 at 3:27 PM, in the administrative conference room, confirmed physical examinations of patients with OB related symptoms were performed by an RN. Continued interview confirmed some patients were not examined by any provider other than the designated OB triage RN. Interview with RN #2 at Hospital B on 12/11/18 at 10:00 AM, in the OB staff work room, confirmed RNs performed physical examinations on patients with OB related symptoms. Continued interview confirmed some patients were not examined by any provider other than the designated OB triage RN. Interview with the Manager of the Child Birth Center at Hospital B on 12/11/18 at 4:00 PM, in the administrative conference room, confirmed the MSE for Patients #36, #37, and #40 were provided by RNs. Further interview confirmed Patients #36, #37, and #40 were not been seen by any other providers prior to discharged from Hospital B.

Based on review of facility policy, medical record reviews, and interviews, on 10/7/16 Hospital A failed to provide stabilizing treatment for an emergency medical condition for one patient (#3) of 33 Emergency Department (ED) patients reviewed. The facility's failure to provide stabilizing treatment resulted in Patient #3 being discharged home on 10/7/16 at 6:17 PM with diagnosis of Headache and Hypertensive disorder even though his Perfusion Computed Tomography (PCT TCA/x-ray using special equipment which shows details of blood flow in the brain) dated 10/7/16 at 6:06 PM, revealed the patient had an Acute Posterior Circulation Stroke (damaged brain tissue caused by a clotted blood vessel in the brain). The patient was discharged home where his symptoms worsened overnight and he returned to the ED on 10/8/16 at 11:04 AM and was diagnosed with an Acute Cerebrovascular Attack (Stroke). The patient was transferred to Hospital B by ambulance on 10/8/16 at 6:39 PM where a right vertebral artery extraction of clots was performed and a CT scan showed the patient to have acute to subacute infarctions (cellular damage) in the right cerebellum of his brain. Refer to A-2407 for failure to provide stabilizing treatment.

Based on policy review, record reviews, and interviews, the facility failed to provide stabilizing treatment within the capability of the staff and facilities available at the facility for one patient (#3) of 33 patients reviewed. The findings included: Review of facility policy "Emergency Medical Treatment & Active Labor Act," dated January 2014, revealed "...If an individual has an emergency medical condition, further medical examination and treatment as is within the hospital's capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility..." The facility's policy on "Communication of Critical Results" Effective 06/05, revised date 5/16 and Approval date by CNO 7/16/2017 was reviewed. The policy stated in part, "purpose: To appropriately and efficiently communicate critical test results that may require therapeutic intervention for serious abnormalities ....Definitions: Critical Result, finding that warrant rapid communication ...Policy Statement/Procedure:" I. Critical results of tests and diagnostic procedures can occur for ...Imaging/Radiology ...and other diagnostic testing in any setting in this organization ...Communication of Critical Results: A. All critical test/critical results must be received by the patient's licensed caregiver ...II. Communication and Notification of Ordering Physician: A. Critical Results ... 2. Call page ordering physician ...Outpatient Communication of Cortical Results: C. Emergency Department (ED): 2. For patients that have left the ED refer to the callback Notification and Documentation in the ED policy." The facility's policy titled "Callback Notification and Documentation in the ED, Effective 4/16 and Approved by: MEC 8/15/2016, was reviewed. The policy revealed in part, "Purpose: To provide guidelines for notification of Emergency Department (ED) patients of finalized test results reported after they have left the ED that require a change in treatment, and for documentation of notification. Policy: Finalized lab and radiology test results reported after the patient's discharge from the ED will be reconciled daily. The ED physician or Mid-Level provider (MLP) on duty will review all the positive results and the treatment and adjust treatment as appropriate. Patients will be contacted by facility designated staff. The notification will on the ...Call Back Notification form and added to the patient's medical record. Procedure: A. Radiology: If a radiological interpretation is not available at the time the Emergency Department physician make a disposition of the patient, the ED physician interpretation will indicated in the medical record. The ED provider will review any positive radiologist interpretation ad make appropriate instructions for further treatment/follow-up as needed. Facility designated staff will contact the patient with further instructions as indicated by the provider ... Callback Procedure: 1. Staff will document all attempts of patient notification on the ... Call back notification form..." Medical record review revealed Patient #3, according to the "Emergency Sign In Sheet" presented to the Emergency Department (ED) at Hospital A (Parkwest Medical Center) on 10/7/16 at 1:37 p.m., "Primary Reason for visit Today: Possible side effects to medication: extreme headache blurry vision/vertigo (dizziness). Review of the Triage and Nursing History revealed the chart was started at 1:44 PM for complaint of headache. The review revealed the Patient's mode of arrival was listed as "Walked In." Further review revealed the patient was triaged by a registered nurse (RN) on 10/7/16 at 1:44 PM and was triaged at a level "...3 Urgent...[patient] states it this is the worse headache he has ever had...denies history of migraines..." Continued review revealed the patient's blood pressure at 1:44 PM was 186/103 (normal 120/80) and the patient's pain was documented as "...8/10..." (on a scale of 1-10 with 10 being severe pain). Further review revealed that at 1:45 PM the ED physician examination was started. The physical examination revealed the patient's general presentation was listed as vital signs were reviewed and the patient appeared to be in no acute distress ... Neurologic ...oriented to person, place, and time ...Musculoskeletal: No extremity tenderness. Review revealed the following medications and nursing procedures were administered by an RN as ordered by the ED physician on 10/7/2016: - Saline lock established at 2:30 PM - Sodium Chloride bolus dose 1000 mg given IV at 2:40 PM; - Morphine injection 2 mg intravenously (IV) for horrible pain (pain scale 8-10) administered at 2:42 PM; - Zofran (for nausea) 4 mg IV administered at 2:43 PM; - Morphine injection 2mg administered IV distressing pan (pain sale 6/10 ) at 3:50 PM; - Oxycodone 5mg/Acetaminophen 325mg administered (discomforting pain (pain scale 4/10) orally at 7:00 PM; - Clonidine 0.1 orally (treatment of Hypertension) administered at 7:00 PM. Further review revealed on 10/7/16 at 1:48 PM a Computed Tomography (CT) Scan of the Brain without contrast was ordered and completed at 3:29 PM. Continued review revealed a CTA (CT Scan with Angiogram) was ordered at 3:45 PM and completed at 6:00 PM. Medical record review of a physician's notes dated 10/7/16 at 6:06 PM revealed "...PCT CTA [Perfusion Computed Tomography (x-ray using special equipment which shows details of blood flow in the brain) scan]...reviewed the radiologist's report for this film. Negative brain imaging study...negative..." Medical record review of a physician's discharge summary dated 10/7/16 at 6:17 PM revealed "...Primary Diagnosis; Headache Hypertensive disorder...Condition at disposition - stable; Disposition decision is discharge..." Documentation also revealed the patient was discharged with a pain score of 4/10. The patient's discharge method indicated the Patient #3 was with his wife and physically left the ED. There was documentation in the medical record to indicate if the patient required assistance with ambulation prior to discharge. According to an interview with the patient's wife it was reported that at discharge the patient had difficulty walking to and getting into the car on 10/7/2016. Medical record review of a "Preliminary Radiology Report" dated 10/7/16 at 7:09 PM revealed "...Focal thrombus [blood clot] in the mid right vertebral artery [an artery in the brain] with 50-70% stenosis [narrowing]. Sequelae [resulting in] localized [nearby] arterial dissection [a tear in the artery wall] is possible...Focal occlusive thrombus or embolus [a mass, such as an air bubble, a detached blood clot, or a foreign body, that travels through the bloodstream and lodges so as to obstruct or occlude a blood vessel] in the basilar artery [an artery that supplies the brain with oxygen rich blood] at the superior cerebral artery origins. Both superior cerebellar arteries have occlusions with..." The comment section the Negative revealed in part, "Comment: Negative CT today CT does not exclude acute infarct. Addendum: I called the CT technologist (name listed) who is confirming the receipt of the preliminary report by the patient's nurse 7:09 PM." (Further review of the report revealed it was faxed to Hospital A's ER by the radiology department on 10/7/16 at 7:11 PM. There was no documentation in the medical record to indicate that Patient #3 and or wife were notified of the critical results of the radiology report dated 10/7/2016. The facility failed to ensure that their policy and procedure was followed as evidenced failing to have a designated person contact Patient #3 with further instructions from the provider as stated in their policy status post discharge form the hospital on [DATE]. Medical record revealed the patient was discharged and left the ED on 10/7/16 at 7:16 PM. Medical record review revealed the patient returned to the ED at Hospital A on 10/8/16 at 11:03 AM via ambulance for complaint of headache. Medical record review of a triage note dated 10/8/16 at 11:04 AM revealed "...Patient was seen in this ER for headache and had a normal head CT...Patients wife states he has been vomiting since last night and pain in his head has increased..." Medical record review of a Nurse's Note dated 10/8/16 at 12:30 PM revealed "...Patient crying in stretcher...Patient not verbalizing to wife at this time...Only nods yes or no and holding up fingers...to answer yes or no..." Medical record review of a physician's notes dated 10/8/16 at 4:00 PM revealed "...Reviewed CT today, CT yest [yesterday] and CTA yesterday. CTA with Thrombus Right Vertebral Artery. Occlusive Thrombus/embolus basilar artery...Primary Diagnosis Posterior Circulation Stroke [damaged brain tissue caused by a clotted blood vessel in the brain]..." Medical record review of a physician's order dated 10/8/16 at 5:00 PM revealed "...Transfer to [Hospital B] dx [diagnosis] acute cerebellar CVA [Cardiovascular Attack/Stroke]...condition serious/guarded...consult neurosurgery on arrival...increased risk cerebellar edema...acute cerebellar cva right..." Medical record review revealed the patient was transferred from Hospital A to Hospital B by ambulance on 10/8/16 at 6:39 PM. Medical record review of a physician's history and physical, from Hospital B, dated 10/8/16 at 9:06 PM revealed "...was transferred to [Hospital B] this evening from [Hospital A] for suffering an embolic CVA...He decided to go to [Hospital A] emergency department on 10/7/2016. CTA of the head and neck was performed which read focal thrombus of the mid right vertebral with 50-70% sequela of localized arterial dissection possible focal occlusive thrombus in the bibasilar artery at the superior cerebellar artery origins both cerebellar arteries have occlusions...Unfortunately the patient was sent home at that time with diagnosis of [DIAGNOSES REDACTED]]...given the fact the patient has had symptomatology greater than the time frame for TPA [tissue plasma activator medication used to dissolve and remove a blood clot from a blood vessel]. He is not a candidate [for TPA treatment]...the patient has decompensated [symptoms have worsened] during the initial interview that I saw him here in the emergency department at [Hospital B] at 1955 [7:55 PM] at 2030 [8:30 PM] has progressed to the point where he has lost control and grip of the right upper extremity and has decreased movement to the right lower extremity...CTA of the head and neck obtained yesterday reveals focal thrombus of the mid right vertebral with 50-70% sequela of localized arterial dissection possible focal occlusive thrombus in the bibasilar artery at the superior cerebellar artery origins both cerebellar arteries have occlusions...Acute thrombotic cerebrovascular accident..." Medical record review of a discharge summary, from Hospital B, dated 10/13/16 revealed the patient was admitted with diagnosis of [DIAGNOSES REDACTED]"...Interventional radiology performed right vertebral artery extraction of clots and also left recanalization of the basilar artery and right middle cerebral artery status post clot extraction...CT scan of the brain performed without contrast after the interventional procedure which showed acute to subacute infarctions [cellular damage] in the right cerebellum...the patient regained some function of the right leg. The right arm still had [DIAGNOSES REDACTED]...He will be transferred to [rehabilitation hospital]..." Further review revealed the patient was discharged to a rehabilitation hospital on [DATE] for continued Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). Telephone interview with Patient #3's wife on 7/13/17 at 11:00 AM revealed the patient was having "the worse headache in his life" along with dizziness and loss of balance beginning the morning of 10/7/16. Continued interview revealed the patient and his wife went to the ED at Hospital A in the afternoon of 10/7/16 and was seen by a physician who appeared very concerned regarding the patient's symptoms and recommended a CT Scan and a CTA with contrast and if those were negative he recommended a lumbar puncture. Further interview revealed the patient remained in severe pain until he was given his second dose of morphine in the ED, after which his symptoms began to improve slightly. Continued interview revealed the CTA with contrast was performed at approximately 6:00 PM and the ED physician came into the room at approximately 6:10 PM and told her and the patient the "...CTA was negative and we are 96% certain that there is nothing to be concerned about..." Further interview revealed the physician offered to perform a lumbar puncture but did not recommend it. Continued interview revealed the patient was given a prescription for pain medication and a prescription for blood pressure medication and discharged from the ED at approximately 7:15 PM. Further interview revealed the patient was unsteady and needed support from her to walk to their car and the patient was severely nauseated and vomited for approximately 10 minutes before he could enter the car. Continued interview revealed the patient remained in severe pain and was extremely nauseated with frequent vomiting all night on 10/7/16 and at approximately 8:00 AM on 10/8/16 the patient was slumped over in the bed, was unable to sit up, and had a noticeable "...droop to the right side of his face..." Further interview revealed the wife called Emergency Medical Services (EMS) and while waiting the patient fell on to the floor and remained on the floor until the first responders arrived. Continued interview revealed the patient was taken by EMS to Hospital A at approximately 10:40 AM and by this time the patient was unable to speak and was unable to move his right arm or leg. Further interview revealed the patient was eventually seen by another physician who told the wife he was going to order a lumbar puncture, but the patient's wife (following the recommendations of a nurse practitioner friend) requested a repeat CTA be performed and the physician ordered a CTA based on the wife's request. Continued interview revealed the patient was taken for the CT at approximately 2:30 PM and the physician came to the room at approximately 3:30 PM and told her and the patient "...the CTA today showed evidence of damage and there was a stroke..." Further interview revealed "...the physician admitted the CT yesterday did show something and it was misread..." Continued interview revealed the patient was not provided any treatment and eventually was transferred to Hospital B at approximately 6:30 PM, where he was quickly taken for surgical removal of the clot. Further interview revealed the patient's condition deteriorated all day on 10/8/16 and after the surgery he continued to be unable to move his right arm and leg, he was unable to swallow, had a feeding tube placed, was unable to speak, and he was incontinent. Continued interview revealed the patient was discharged to a rehabilitation hospital for continued rehabilitation on 10/13/16, where he remained for 3 weeks, and the patient currently has weakness, limited use in his right arm and leg, difficulty with speech, and incontinence. Interview with the ED Supervisor on 7/10/17 at 2:00 PM, in an administrative office, revealed Patient #3 came to the ED at Hospital A on 10/7/16 for a complaint of a headache. Further interview revealed a CT and a CTA scan was performed, but the patient was discharged before the results were sent to the ED. Further interview revealed the patient returned to the ED on 10/8/17 with increased headache and neurologic deficits and was transferred to Hospital B. Continued interview confirmed Hospital A had teleneurology (access to neurology services via internet/computer contact) services available on 10/7/16, which were not provided for this patient. Interview with Hospital A's Senior Risk Manager (SRM) on 7/12/17 at 10:20 AM, in an administrative office, confirmed the physician notes documented the PCT CTA results were negative on 10/7/16 at 6:06 PM. Further interview confirmed the PCT CTA results were interpreted by radiology at 7:09 PM and faxed to the facility on [DATE] at 7:11PM. Interview with Physician #3, a Neurology Hospitalist at Hospital A, on 7/12/17 at 11:10 AM, in an administrative office, revealed Physician #3 was not involved in the care of Patient #3, but based on his review of the radiology reports Patient #3 "...definitely needed hospitalization ..." Further interview revealed the physician believed the patient needed additional diagnostic tests and depending on the test results, may have needed vascular interventions to remove the clot obstructing the blood vessels.

Based on policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination for one patient (#6) of twenty-five Emergency Department (ED) patients reviewed. The findings included: Refer to A2406 for the facility's failure to provide a Medical Screening Exam.

Based on policy review, medical record review, and interviews, the facility failed to provide an appropriate medical screening examination for one patient (#6) of twenty-five Emergency Department (ED) patients reviewed. The findings included: Review of Hospital #1's Emergency Medical Treatment and Active Labor Act Guidelines, effective date 1/14, revealed, "A Medical Screening Examination (MSE) will be performed for any individual that 1) presents on hospital property and requests examination...The Medical Screening Examination may include...Ancillary testing and/or prior procedures as deemed necessary to rule out the presence of an EMC [Emergency Medical Condition]...Other examinations, tests, or procedures as deemed necessary..." Medical record review of an Emergency Medical Service's (EMS) Patient Care Report dated 2/26/15 revealed Patient #6 was transported from her home on 2/26/25 at 2:14 AM, and arrived at Hospital #1 at 2:55 AM. Further review of the Patient Care Report revealed the patient was complaining of abdominal pain and vomiting, with blood pressure 130/80 (normal is 119/79 or below), pulse 72 (normal pulse is 60-100), and respirations 16 (normal respirations is 12-20). Further review of the Patient Care Report revealed, "...Transport from residence to Parkwest was without incident...Pt [patient] was unable to ambulate due to pain..." Medical record review of the ED Record dated 2/26/15, revealed Patient #6 arrived at Hospital #1, by ambulance, on 2/26/15 at 3:04 AM for complaint of abdominal pain. Further record review revealed the patient was triaged at 3:04 AM with blood pressure of 170/97, pulse 142, respirations 18, PulseOx 97% (level of oxygen present in the blood/normal 92-100%), and temperature 99.5 degrees (normal 98.6). Further record review revealed at triage, the patient was complaining of severe pain at level "10" on a scale of 1-10 (1 being mild pain, 10 being severe pain). There was no documentation of any diagnostic tests being ordered or performed. There was no documentation of any medications being prescribed or administered to the patient. Medical record review of the Physical Exam revealed the patient was seen at Hospital #1 by a Medical Doctor on 2/26/15 at 3:17 AM. Further review of the Physical Exam revealed, "...Alert and oriented and responds appropriately to questions; well appearing; well nourished...A 10 system review of systems was performed and is negative for acute complaints..." Medical record review of the Discharge Summary dated 2/26/15 at 3:21 AM revealed, "...Primary Diagnosis: Abdominal pain...Disposition decision is discharge; Condition at disposition - stable..." Medical record review of the physician documentation in the Progress Notes at Hospital #1 on 2/26/15 at 3:30 AM revealed, "...Here with abdominal pain. She no longer has constipation. She is adamant about receiving pain medicines. I am more than happy to order tests and labs to try to dx [diagnose] cause of her pain but I am not comfortable giving her pain medicine. Gave usual abdominal pain unknown cause talk. Discussed with pt evolving symptoms. The patient agrees and understands plan. Will f/u [follow-up] with PCP [primary care physician] in 2-3 days. Will return to ER [emergency room ] if worsening in any way, shape or form..." There was no documentation that the patient refused diagnostic tests. There was no documentation that the patient left against medical advice. Medical record review of the Disposition note dated 2/26/15 revealed, "...A discharge pain score was documented: Pain 0/10 (no pain) at 4:04..." Further review of the disposition note revealed the patient left the ED at 4:04 AM. Medical record review of an ED Triage sheet from Hospital #2 revealed Patient #6 presented to Hospital #2 on 2/26/15, at 5:44 AM, complaining of stomach pain and stating, "...we just came from park west and they didn't do anything...". Further review of the triage sheet revealed blood pressure 146/91, pulse 90, temperature 98.9 and pain level "6" on a scale of 1-10. Medical record review of the Emergency Provider Record at Hospital #2 revealed the patient was seen and examined by a physician on 2/26/15 at 6:15 AM. Further review of the Emergency Provider Record revealed diagnostic tests were performed, which included: Complete Blood Count (CBC/a blood test used to evaluate your overall health and detect a wide range of disorders, including anemia and infections), Chemistry Panel, Urinalysis, and a Computerized Axial Tomography (CT/ a computer assisted x-ray) Scan of the abdomen. Medical record review of the results of the diagnostic tests performed at Hospital #2 on 2/26/15 revealed the patient's white blood cells (WBC), an indicator of possible infection, was 16.9 (normal range 4.4-11.0), and the CT scan was "...most suggestive of enteritis. Multiple slightly enlarged mesenteric lymph nodes are presumably reactive. A 4.7 cm [centimeter] right ovarian cystic lesion, likely representing an ovarian cyst...Recommend followup with pelvic ultrasound in 6 weeks..." Medical record review of the Hospital #2 records revealed there was no documentation of the patient requesting drugs or pain medications. Further review of the Emergency Provider Record revealed the patient was admitted to Hospital #2 on 2/26/15 with diagnosis of [DIAGNOSES REDACTED] Medical record review of a Discharge Summary from Hospital #2 dated 3/6/15, revealed Patient #6 was admitted to Hospital #2 on 2/26/15 with diagnoses which included: Sepsis on Admission, Enteritis, Nausea, Vomiting, Right Lower Lobe Pneumonia, Anxiety, Anemia, [DIAGNOSES REDACTED], Ovarian Cyst, Constipation, Ankle Pain, and Abnormal Urinalysis. Further review of the discharge summary revealed the patient was discharged from Hospital #2 on 3/6/15 (8 days later) in stable condition. Interview with Patient #6 by telephone on 5/7/15 at 1:30 PM, revealed the patient did remember her visit to Hospital #1 on 2/26/15. The patient stated she did not receive good care on her visit on 2/26/15. Patient #6 stated, "...it was snowing and a fire truck had to pick me up and take me to the ambulance because the ambulance could not make it to my house...I was sick and vomiting in the ambulance..." The patient stated that when she arrived at the hospital, "...the doctor came in immediately and said I can't give you any pain meds...the doctor did no blood tests, no x-rays, no urinalysis, nothing...they discharged me and I couldn't even walk...I was still in pain and vomiting...my mom came and picked me up in the snow...I was also having anxiety...Ask a Nurse [insurance provider's nurse help line] called me back...I was supposed to go to [Hospital #2] but the ambulance took me to [Hospital #1] instead...I told Ask a Nurse that I was still in pain and vomiting and the nurse told me to go to [Hospital #2]...my mom took me to [Hospital #2] and they did lab tests and a CT scan...gave me IV [intravenous] and antibiotics and put me in the hospital for 9 days...they said I had fluid on my lung, dehydration, stomach virus, and a urinary tract infection..." The patient stated she had not been hospitalized or seen a physician since being discharged from Hospital #2. A second telephone interview with Patient #6 on 5/14/15 at 10:45 AM revealed, "...I was still in pain when I left Parkwest...I did not ask for any pain medicine when I came in, when he told me I was being discharged I told him, 'I am in pain. I can't sleep.' He told me it was against the law for him to give me pain medicine...I did not want to leave but they discharged me and made me go...I had to wait out in the waiting room for my mom to pick me up...then she took me to UT where they admitted me..." When asked about the severity of her pain at discharge the resident described the pain as a "10" on a scale of 1 to 10 with 10 being severe pain and 1 being mild pain. Further interview with the patient, when asked if she had been offered lab tests or xrays by the doctor revealed, "...no they did not offer to do any tests...I did not refuse any tests, they did not offer me any...he just came in and said he was not allowed to give me any pain medicine and that he was going to discharge me..." Interview with Physician #1 (the MD that saw Patient #6 at Hospital #1 on 2/26/15) by telephone on 5/11/15 at 2:10 PM revealed he did not remember this patient. Telephone interview with Registered Nurse (RN) #1 (nurse involved in Patient #6's care and discharge on 2/26/15) on 5/11/15 at 2:45 PM revealed, after reviewing the medical record, "...I remember that night...the doctor didn't order anything..." Interview with Physician #2 (who admitted and treated Patient #6 at Hospital #2 on 2/26/15) revealed he had reviewed Patient #6's medical record and did not remember this specific patient. After reviewing the medical record the physician stated, "...she definitely met criteria for admission...had signs and symptoms of [DIAGNOSES REDACTED]"