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Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24 related to Patient #6, one of 30 medical records reviewed.

The findings include:

1. Based on policy review, medical record review and staff and physician interviews the hospital failed to obtain signature of Patient #6's refusal for further evaluation or document in the medical record attempts to obtain written refusal for one of 30 medical records reviewed. (Patient #6)

~ Cross refer to Stabilizing Treatment - Tag A2407.

Based on policy review, medical record review and staff and physician interviews the hospital failed to failed to obtain signature of Patient #6's refusal for further evaluation or document in the medical record attempts to obtain written refusal for one of 30 medical records reviewed. (Patient #6)

The findings included:

Review of the policy "EMTALA [Emergency Medical Treatment and Labor Act] COMPLIANCE...", reviewed/revised 02/2020, revealed "...Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the emergency department' and request examination or treatment of a medical condition....A Medical Screening Examination will be done to determine if an Emergency Medical Condition exists. If the individual has an Emergency Medical Condition, the hospital will either stabilize the medical condition within its available staff, facilities, and resources, or, if stabilization at the hospital is not possible, appropriately transfer the individual to a qualified receiving facility. ..."

Review of the Dedicated Emergency Department [DED] record for Patient #6 on 08/09/2023 revealed Patient #6, a 52-year-old arrived to Campus B [a free-standing ED] on 05/26/2023 at 1130 with "...Chief Complaints.... Numbness.... Extremity Weakness (Pt [Patient] states.... woke this am at 0800. States she was unable to raise and lower her left arm. She notes that she has numbness in the left hand palm and finger tips. States after 5 minutes she states [sic] movement ability returned to normal. Pt has hx [history] of trigeminal neuralgia [chronic pain condition affecting the trigeminal nerve in the face]. States she contacted Neurologist this am who recommended she come to the ED for evaluation. Pt .... also states she seems to have a cervical nerve issue that may be causing her sx [symptoms]. Pt denies any other neuro deficits.) ... Headache (Pt states she typically has a left sided headache and facial pain. Today says headache seems to be slightly worse in intensity. Other than that it is a typical pain.) .... Hypertension (Pt states she has a hx of hypertension [elevated blood pressure]. Taking Lisinopril 40mg PO q day [40 milligrams orally every day]. Has 'water pill' as well for hypertension. States 'I am very bad at remembering to take it' Unsure when she took last dose.) Review of the ED Care Timeline revealed the following tests were ordered: Head CT (Computed Tomography), EKG (electrocardiogram), CBC (complete blood count), Basic Metabolic Panel and Troponin. At 1146 the patient's blood pressure was noted to be 152/120 [high] and there was a pain score noted of 6 for pain on the face [on a scale of 0-10 with 0 being no pain and 10 being the worst pain]. An IV was started at 1148. The head CT without contrast resulted at 1217 with "... Impression: No acute intracranial pathology. ..." Review of the "ED Provider Note" by DO #1, date of service 05/26/2023 at 1135, revealed "....Time Seen ....1131 ....History of Present Illness Patient is a 52-year-old female who presents for resolved left arm weakness.... medical history significant for hypertension, pre diabetes....Raynaud's disease [condition in which some parts of the body feel numb or cool at certain times] and trigeminal neuralgia. She does follow with neurology for her trigeminal neuralgia. Patient states she woke up with her symptoms this morning. She states that she felt like she could not use her left arm. She notes that she tried to lift it but it would simply drop back down to her side. She states she has some tingling in her fingers. She states that it resolved after about 5 minutes. She denies any associated headache, visual disturbance. Denies chest pain or shortness of breath. She states she called her neurologist who recommended she come to the ER as this could potentially be a stroke." The Provider Note further revealed "...Medical Decision Making [Patient #6]....presents for left arm numbness that lasted for about 5 minutes. She was hypertensive on arrival but otherwise hemodynamically stable. Blood pressure improved to 150/78 without intervention. Physical exam at the time of arrival is unremarkable, neurologic exam is nonfocal and her NIH stroke scale is 0. Because the patient had woken up like this, she is certainly not within any window for medication such as tPA or TNK (clot busting medications). Thus, code stroke was not activated. EKG was obtained reviewed interpreted by myself as negative for ischemic changes or arrhythmia. Labs were obtained and were unremarkable. Troponin is negative. Noncontrast head CT was obtained and was negative per my interpretation and confirmed by radiology, no intracranial hemorrhage, mass or ischemic changes noted. Patient continued to be symptom-free for the duration of her ER visit. Discussed with the patient that thus far her work-up is extremely reassuring but really the only way we can rule out small or minor stroke is with MRI (magnetic resonance imaging). Discussed with the patient that I cannot obtain an MRI here and that this would require admission for MRI. She asks if I can order an outpatient MRI for her which I explained I am unable to do so being an ER physician. This would need to be done by either primary care physician or her neurologist. Patient declines admission at this time. Patient tells me that her neurologist has told her previously he believes she has a cervical nerve issue which likely resulted in her trigeminal neuralgia and headaches. Patient and I discussed that since her [sic] were present upon awakening, that she had her arm out and abducted to the side as it was wrapped around her dog and that they rapidly resolved after about 5 minutes that I suspect this was more peripheral. However, I was very adamant and clear with the patient that I cannot fully rule out stroke again without MRI. Again, she declines admission. Reasons for returning were discussed. Patient verbalized understanding of the discharge instructions and agreed with the plan of care.....Diagnosis: 1. Left arm weakness [space] Disposition: Discharge. ..." Record review revealed Patient #6 was discharged at 1255. Record review did not reveal the patient signed out against medical advice [AMA]. Review revealed Patient #6's blood pressure was elevated on arrival and other than the doctor's note that it had decreased without intervention there were no further vital signs documented. Further review did not revealed a neurology consult was obtained prior to discharge for outpatient follow-up.

Telephone interview on 08/09/2023 at 1415 with RN #2 on 08/09/2023 at 1415 revealed the RN recalled Patient #6. Interview revealed the facility did not have an MRI on their premises.

Telephone interview on 08/09/2023 at 1520 with DO #1, revealed Patient #6 called the ED prior to arrival. Interview revealed the patient did not want to go to a facility without tPA. Interview revealed DO #1 spoke with Patient #6 and explained that because the patient woke up with the symptoms, they did not have a way of knowing how long they had gone on, so the patient would not qualify for tPA. Interview revealed DO #1 talked with Patient #6 at length and explained it was a neuro complaint and could be a stroke. DO #1 explained they would do a head CT emergently, and if there was still concern then admission was suggested for further testing including a MRI, Echo, cholesterol and other blood work. Interview revealed Campus B did not have an MRI. Interview revealed the DO documented in detail the conversation that was held with Patient #6 and stated the patient did not want to be admitted/ transferred. Further interview revealed DO #1 was very frank in the conversation and stated there was no way to determine if it was a stroke without the MRI and Patient #6 still did not want admission. Patient #6, DO #1 stated, had an outpatient neurologist and wanted that physician to order the test as an outpatient. DO #1 indicated Patient #6 was encouraged to return anytime if needed but explained to the patient if they did not want to transfer, to report to one of two close hospitals vs. a freestanding ED. In relation to discharge vs. AMA [leaving against medical advice], the DO stated "I have my own opinions about AMA" and indicated that there had been much discussion among providers about "shared decision making," Interview revealed DO #1 tried to stay away from AMA because it set a negative tone.

Interview with Charge Nurse (CN) #4, on 08/10/2023 at 0950, revealed CN #4 was Charge Nurse on the day of Patient #6's visit. Interview revealed the physician offered admission and further workup and patient #6 refused. Interview revealed it was up to the provider whether to discharge or AMA. Interview revealed the last thing that was discussed with Patient #6 was the need to follow-up and the patient was going to get with her neurologist.

In summary, Patient #6 presented with transient weakness/numbness of the left arm and the physician noted that stroke could not be ruled out without MRI. Patient #6 required admission for MRI, neurology consult and repeat vital signs. This did not happen. The patient declined admission and was discharged for outpatient follow-up/MRI. Patient #6 should have been advised to stay and signed out AMA if refused admission/transfer.