HospitalInspections.org

Based on interview, record review, and facility policy review, the facility failed to ensure timely completion of a stroke assessment and administration of ordered medications for 1 (Patient 2) of 4 sampled patients.

Findings include:

A facility policy titled, "Acute Stroke Policy and Procedure for Management through Continuum of Care," approved 02/21/23, indicated, "Purpose: to define the criteria used to triage stroke patients and outline the one call code stroke activation alert. To define roles and responsibilities of the interdisciplinary clinical team that will be caring for the acute stroke patient throughout the continuum of care. Policy: This policy applies to all members of the interdisciplinary stroke team who are involved in the acute work-up of the suspected stroke patient at [facility name]. It is the policy of [facility name] to treat all stroke patients according to consensus-based national standards for stroke care. All patients, 18 years of age and older, exhibiting stroke-lie symptoms will be managed utilizing clinical practice guidelines in an organized approach. [Facility name] is committed to meeting the patient's individual needs, either onsite or by transferring to a facility capable of providing services to optimize the patient's outcome."

A patient demographic sheet revealed Patient 2 arrived at the facility on 05/05/25 at 7:13 PM with a chief complaint of numbness on the left side of their face and arm. Patient 2's triage assessment dated 05/05/25, revealed Registered Nurse (RN) #5 triaged Patient 2 on 05/05/25 at 7:15 PM, with a triage acuity level of two and a National Institute of Health Stroke Scale (NIHSS) assessment that was partially done to reveal a score of one.

Patient 2's "Code Stroke Documentation" revealed RN #4 documented that a code stroke was entered on 05/05/25 at 10:31 PM; however, there was no documented evidence that a full NIHSS assessment was completed.

Patient 2's physician orders and medication administration record revealed sodium chloride intravenous fluids were ordered for the patient on 05/06/25 at 2:56 AM and administered to the patient on 05/06/25 at 10:31 AM.

During a concurrent interview and record review on 08/26/25 at 2:59 PM, RN #3 stated she did not remember Patient 2. RN #3 reviewed Patient 2's medical record and acknowledged the order was placed around 3:00 AM on 05/06/25 and IV fluids were not administered until 10:31 AM. RN #3 confirmed IV fluids or medications, in general, should be administered within an hour of the order.

During an interview on 08/26/25 at 2:25 PM, RN #2 stated her expectations were IV fluids be administered within an hour after the order was placed.

During an interview on 08/27/25 at 2:40 PM, RN #5 stated during triage staff usually performed a brief NIHSS assessment and emergency severity index to get patients to a bed as soon as possible for imaging. RN #5 stated she no longer worked at the facility but knew that the process changed to allow nurses to call stroke codes, whereas previously only providers could do so. She explained that around June 2025 the process changed to zones and providers were then assigned patients. She stated she did not recall caring for Patient 2 on 05/05/25 or notification of the provider of stroke symptoms.

During an interview on 08/27/25 at 11:48 AM, RN #4 stated a full NIHSS assessment should have been completed immediately once a nurse was assigned to the patient.

During an interview on 08/27/25 at 9:08 AM, the Emergency Department Director (EDD) reviewed Patient 2's medical record and stated the patient arrived at 7:13 PM, was triaged at 7:20 PM, and assigned a bed at 7:23 PM. The EDD stated a code stroke was called at 8:52 PM according to the ED activity log. The EDD stated providers at that time were only able to call a code stroke; however, now the nurses were able to call code strokes as well. The EDD stated changes were made in May 2025 to allow nurses and providers to active a code stroke and inform the pharmacy if tenecteplase (an injection medication that dissolved blood clots in certain blood vessels in the body) was required. She explained Medical Doctor (MD) #1 assigned himself to Patient 2 at 8:14 PM and saw the patient at 8:25 PM. Per the EDD, RN #5 performed an abbreviated NIH which yielded a score of one during triage, which was documented as a note in the triage record. She stated her expectations was for RN #5 to have notified the provider immediately of the stroke like symptoms. The EDD stated a full NIHSS assessment was not completed until 11:30 PM. According to the EDD, her expectations was for a full NIHSS assessment to be completed upon triage. She clarified that the triage nurse's role was to place the patient in a triage room and complete an initial triage while the assigned RN was responsible for completing the NIHSS assessment.