HospitalInspections.org

1. Based on review of medical records, ambulance report, Medical Staff Rules and Regulations, American Academy of Neurology Guidance for focal neurological assessment, On-call schedules, facility license, facility policies and Procedures and staff interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department to include ancillary services, (on-call Neurology and/or Neurosurgery) routinely available to the Emergency Department to determine whether or not an emergency medical condition exists for 1 (#11) of 20 sampled patients prior to discharge. Refer to findings in Tag -2406.

2. Based on review of medical records, American academy of Neurology guidance for focal neurological assessment, facility license, physician on call schedules, facility Policy and Procedure and staff interviews, it was determined the facility failed to provide stabilizing treatment as required within the capabilities of the staff and capabilities available at the hospital to include on-call neurologists and/or on call neurosurgeons for further evaluation and treatment to stabilize a medical condition for 1 (#11) of 20 patients sampled. Refer to findings in Tag A-2407.

Based on review of medical records, ambulance report, Medical Staff Rules and Regulations, American Academy of Neurology Guidance for focal neurological assessment, On-call schedules, facility license, facility Policies and Procedures and staff interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department to include ancillary services, ( on-call Neurology and/or Neurosurgery) routinely available to the Emergency Department to determine whether or not an emergency medical condition exists for 1 (#11) of 20 sampled patients prior to discharge.

Findings include:

The ambulance report for Patient #11 was reviewed. A review of the " County Emergency Medical Services/Patient Care Report" revealed that Patient #11 was found on the ground at the scene of the accident on 4/6/2017 7:06 p.m. Further review of the section titled "Scene Information" revealed in part, "Can patient Get up w/o (without) Assist- No; Can pt. (patient) ambulate: No; Can pt. sit in a chair or wheelchair?- No." ... CHIEF COMPLAINT: Paralysis ...Traumatic injury. NARRATIVE: Pt. states he was riding his bicycle out of storage facility when the gate closed on him, hitting him in the head, he fell off his bicycle, he is experiencing pain in his head and loss of sensation below the stomach. FD (Fire Department) states she tried painful stimulus, confirms pt. has loss of sensation below the waist. Pt. states he did his head and lose consciousness. See. Assessment. Found pt. supine in roadway with FD holding manual CSPINE. Pt is alert and oriented x 4. Pt. has no neuro activity below waist, with strong distal pulses. Pt has +PMS in upper extremities. Lungs clear and equal x 4. Pt. has blood draining from his nose. Head to toe assessment is otherwise unremarkable, Vitals and diagnostics as documented. ..Treatment and transport as documented. Pt placed in full SMR, without change in neurological response for duration. Transferred pt. to ED bed ...Transferred pt. care and report to staff at bedside without incidence ...Impressions: Primary Impression: Neuro Paraplegia (Lower); Secondary Impression: Inj (injury) Back Injury. Assessments ...Body Area ...Cranial Nervous System Lower extremity: paraplegia. Abdomen: Soft and Non Tender ... Trauma Description: Red Alert Criteria: Suspected spinal cord injury."

A review of the history and physical record for Patient #11 revealed the patient was a 38 year old uninsured patient brought to the facility by ambulance on 04/06/17 at 7:20 PM after having had a bicycle accident that resulted in a loss of consciousness with a head injury and loss of sensation from the hips down. The medical record indicated the patient was suspected to have a spinal cord injury. The patient was considered a level 1 (the highest level) trauma alert.

A review of the "General Consent For Tests, Treatment, Photo, Video and Services" for Patient #11 documented: The Facility must treat medical emergencies regardless of my ability to pay. If I or my guarantor have a medical emergency... I have the right to receive, within the capabilities of this Hospitals staff and facilities, an appropriate medical screening exam, stabilizing treatment, and if medically necessary, an appropriate transfer to another hospital, even if I cannot pay or do not have medical insurance or am not eligible to receive Medicare or Medicaid. The form was not initialed or signed by the patient. The hospital documented on the initial lines and signature lines that the patient was unable to sign. The same information of patient unable to sign was documented on the Notice of Patient Rights and Responsibilities.

A review of the Registered Nurse (RN) nursing note documentation dated 04/06/17 at 7:20 P.M. showed the patient arrived via emergency medical services (EMS) status post fall off bike with loss of sensation from the hips down. The patient was noted to be alert and oriented to person, place, time and situation. Patient #11 was noted to be anxious and tachypneic (rapid breathing greater than 20 breaths per minute). The patient was noted to have an abrasion to his nose, forehead and right side rib. The patient complained of numbness and tingling of his bilateral lower extremities (BLE). Pain was elicited to the BLE with no movement. The patient was rolled off the backboard at this time. At 7:40 P.M., the patient was medicated with 2 mg of Versed (medication used for anesthesia and sedation). At 7:45 P.M., that patient was taken to cat scan (CT) for a scan of the neck and head.

A review of the ED attending physician's Final Report dated 04/06/17 at 7:33 P.M., showed the patient was not wearing a helmet and was going through a security gate when the gate closed and clipped the back end of the bike causing the patient to fly forward. The patient was noted to have lost consciousness and complained of numbness to his lower extremities. The attending physician's neurological assessment was noted as the following: no headache, no dizziness, alert and oriented to person, place, time and situation with no focal neurological deficit observed (no deficit with nerves, spinal cord, or brain function). The physician's assessment of the head showed the following: normocephalic (normal head) and atraumatic (no trauma). The skin was noted to have a 1 cm vertical laceration to the midline of the forehead and a linear like abrasion to the right chest wall.

A review of the CT scan results completed on 4/6/17 at 8:18 p.m., and electronically signed by the radiologist on 4/6/17 at 8:35 p.m. showed the clinical information provided to radiology was as follows: Fall. 38 year old male complains of bilateral upper extremity tingling and pain. The report contained no information for radiology related to the patient's lack of sensation and movement below the hips, the patient's complaints of numbness and tingling of BLE, or that the patient had lost consciousness after the accident. CT results of the brain and cervical spine indicated there were no acute findings.

Continued review of the ED physician's Final Report showed that at 10:00 PM a diagnosis was made of abrasion to the face and musculoskeletal pain. There was no diagnosis of paralysis of the BLE or numbness and tingling of the bilateral upper extremities (BUE). Condition was noted to be improved and stable. The patient was instructed to follow up with the facility trauma surgeon in 72 hours and return to the ED for increased pain, vomiting or fever. The patient was cleared for discharge home by the ED trauma surgeon. A complete and thorough review of the medical record failed to reveal any documentation of an assessment of any kind by the trauma surgeon that discharged Patient #11.

A review of the discharge instructions dated 04/06/17 at 9:40 P.M., provided by the RN, revealed the patient was provided with information on a "cervical strain." This was not noted as a diagnosis by the attending physician that assessed the subject patient. The discharge instruction indicated the patient should seek immediate medical care if numbness, tingling, weakness, or paralysis in any part of the body should occur. The discharge note was not signed by the patient and it was noted he refused to sign the document and was argumentative towards staff and resisted bending his legs to get into the wheelchair.

An interview with the Director of Emergency Services on 4/2/18 at approximately 2:45 p.m. confirmed the above findings in the medical record of Patient #11 at this hospital.

An interview on 04/02/18 at 4:20 PM, with the attending ED physician that cared for Patient #11, revealed that a full neuro assessment would include; strength, sensation, reflexes, coordination, and a Babinksi test. She further stated, "my objective assessment was he could move but his subjective assessment was he could not." The physician stated, "No, I did not do a focused neurological assessment."

According to American Academy of Neurology guidelines for a focused neurological assessment; the major areas of the exam, covering the most testable components of the neurological system, include:
o Mental status testing
o Cranial Nerves.
o Muscle strength, tone and bulk.
o Reflexes.
o Coordination.
o Sensory Function.
o Gait.
A complete and thorough review of subject patient's medical record failed to reveal the presence of a focused neurological assessment but rather it was documented that there were no neurological deficits observed.

An interview performed on 04/03/18 at 3:43 PM with the facility radiologist revealed that if a patient came in with new onset paralysis and negative CT findings, a magnetic resonance imaging (MRI) should be ordered per the standard of care. There was no documentation in the medical record that an MRI was ordered or performed.

An interview with the trauma surgeon on 4/2/2018 at 3:00 p.m. confirmed that there was no assessment completed by him in Patient #11's medical record. He stated, I may have been remiss about charting my assessment.

A phone interview on 04/02/18 at 3:15 P.M. with the RN that documented that the patient resisted bending his legs to get into the wheelchair, stated she could not remember who brought the patient from the wheelchair to the car or how he was assisted into the car. The RN stated the patient said he could not move his legs but was actively pushing against her as she was trying to get him into the wheelchair. The RN stated she felt the patient appeared to be a transient with poor hygiene and did not want to leave. She also stated the patient was noncompliant with the discharge instructions and stated he felt there was something wrong with him. The RN said she told the patient that his CT was negative. She further stated, when the patient first arrived he was unable to move his feet but after the CT scan, he moved his feet when pain was elicited.


Further investigation and review of another acute care hospital's medical records (Facility A) revealed that on 04/17/17 Patient #11 presented to Facility A with complaints of ongoing BLE paralysis and BUE numbness and tingling. Review of the ED physician's H&P revealed the following focused neurological assessment: patient is unable to stand and unable to move arms above the chest level; motor weakness to both upper extremities. Decreased grip strength, unable to fully flex or extend all fingers. Sensation: numbness, that is severe, of the right hand and left hand. Gait: unable to stand and bear weight. Continued review of the physician note showed the following: MRI supports diagnosis of C4, C5, and C6 cervical spine anterior cords syndrome and patient needs to be transferred to another facility for a higher level of care. Facility B was contacted and the case was discussed with a neuro trauma surgeon. The patient was accepted by the neurology trauma surgeon at Facility B due to a spinal cord injury and need for spinal cord decompression. Review of Facility B's neuro surgery discharge summary dated 05/05/17 showed a principal diagnosis of cervical spinal cord compression and a secondary diagnosis of quadriplegia/quadriparesis.


A review of the facility Medical Staff Rules and Regulations, dated September 2016, showed the following:
An Emergency Medical Condition (EMC) means (1) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain ...such that the absence of immediate medical attention could reasonably be expected to result in (a) placing the health of the individual ...in serious jeopardy, (b) serious impairment to bodily function, or (c) serious dysfunction of any bodily organ or part. Continued review of the Medical Staff Rules and Regulations, Medical Records, I. General, showed that it is the policy of the hospital to ensure a uniform medical record, which contains sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and results accurately...it is a basic responsibility of staff membership to prepare and complete in the prescribed manner, medical and other required records for all patients a staff member admits or in any way provides care to in the hospital.

A review of the facility's license revealed the effective date of the license was 4/1/2017 and expiration date 3/31/2019. Further review revealed the description of services (capability) offered at the hospital in part were "Neurology and Neurosurgery services."

The Neurology and Neurosurgery On Call schedule for April 2017 was reviewed. The on-call schedule revealed that on April 6, 2017 that ancillary services to include an on-call Neurologist and/or Neurosurgeon were available to the hospital's emergency department to assist with determining whether or not an emergency medical condition existed for patient # 11 when he continued to complain of lower extremity numbness and the inability to ambulate prior to discharge.
A review of the policy entitled, "Trauma Service Structure Standard XIV: Spinal Cord Injuries", reviewed 09/09/2016, showed all spinal cord injured patients arriving at Bayfront Health St. Petersburg will be evaluated and stabilized. The ED physician/trauma surgeon will contact an appropriate on-call specialist who will evaluate and provide acute care for the patient. There was no documented evidence in the medical record to indicate that the on-call neurologist or neurosurgeon was called to evaluate patient #11 on 4/6/2017, who presented to the ED by ambulance with suspected spinal cord injuries, and the patient's continued complaint of LE numbness prior to discharge.

Based on review of medical records, on-call schedules, American academy of Neurology guidance for focal neurological assessment, facility license, facility Policy and Procedure and staff interviews, it was determined the facility failed to provide stabilizing treatment as required within the capabilities of the staff to provide to stabilize a medical condition for 1 (#11) of 20 patients sampled.

Findings included:

A review of the emergency department (ED) attending physician's history dated 04/06/17 at 7:33 P.M., showed Patient #11 was a 38 year old uninsured patient brought to the facility by ambulance as a level 1 (the highest level) trauma alert. Documentation by the ED physician showed the patient was not be wearing a helmet and was going through a security gate when the gate closed and clipped the back end of the bike causing the patient to fly forward. The patient was noted to have lost consciousness and complained of numbness to his lower extremities. The attending physician's neurological assessment was noted as the following: no headache, no dizziness, alert and oriented to person, place, time and situation with no focal neurological deficit observed (no deficit with nerves, spinal cord, or brain function). The physician's assessment of the head showed the following: normocephalic (normal head) and atraumatic (no trauma). The skin was noted to have a 1 cm vertical laceration to the midline of the forehead, a linear like abrasion to the right chest wall. Continued review of the physician's Final Report showed that on 4/6/17 at 10:00 PM a diagnosis was made of abrasion to the face and musculoskeletal pain. There was no diagnosis of paralysis of the BLE or numbness and tingling of the bilateral upper extremities (BUE), nor of a cervical strain. Condition was noted to be improved and stable. Patient was instructed to follow up with the facility trauma surgeon in 72 hours and return to the ED for increased pain, vomiting or fever. There were no ongoing documented neurological assessments by the attending ED physician.

An interview on 04/02/18 at 4:20 PM, with the attending ED physician that cared for Pt. #11, revealed that a full neuro assessment would include; strength, sensation, reflexes, coordination, and a babinksi test. She further stated, "my objective assessment was he could move but his subjective assessment was he could not." The physician stated, "No, I did not do a focused neurological assessment."

According to American Academy of Neurology guidelines for a focused neurological assessment; the major areas of the exam, covering the most testable components of the neurological system, include:
o Mental status testing
o Cranial Nerves.
o Muscle strength, tone and bulk.
o Reflexes.
o Coordination.
o Sensory Function.
o Gait.

A complete and thorough review of subject patient's medical record failed to reveal the presence of a focused neurological assessment but rather it was documented by the ED attending physician that there were no neurological deficits observed.

A review of the facility's license revealed the effective date of the license was 4/1/2017 and expiration date 3/31/2019. Further review revealed the description of services (capability) offered at the hospital in part were "Neurology and Neurosurgery services."

The Neurology and Neurosurgery On Call schedule for April 2017 was reviewed. The on-call schedule revealed that on April 6, 2017 a Neurologist and/or Neurosurgeon were available and on call to provide further evaluation and treatment for patient #11. The facility failed to ensure that there policy and procedure was followed as evidenced by failing to have the appropriate on call specialist (neurologist or neurosurgeon) who were available on 4/6/2017 to provide stabilizing evaluation/care and treatment for patient #11 who presented to the hospital's emergency department with suspected spinal cord injuries.

A review of the CT scan results completed on 4/6/17 at 8:18 p.m. and electronically signed by the radiologist on 4/6/17 at 8:35 p.m. showed the clinical information provided to radiology was as follows: Fall. 38 year old male complains of bilateral upper extremity tingling and pain. There was no clinical information documented for radiology that the patient had lack of sensation and movement below the hips or that the patient had lost consciousness after the accident. CT results of the brain and cervical spine indicated there were no acute findings.

An interview performed on 04/03/18 at 3:43 PM with the facility radiologist revealed that if a patient came in with new onset paralysis and negative CT findings, an magnetic resonance imaging (MRI) should be ordered per the standard of care. There was no documentation in the medical record that an MRI was ordered or performed.

Continued review of Pt. #11's medical record showed the patient was cleared for discharge home by the ED trauma surgeon. A thorough review of the medical record failed to reveal any documentation in the record that the trauma surgeon performed an assessment. Additionally, there was no documentation that an on-call specialist was contacted or provided care for Pt. #11.

An interview with the trauma surgeon on 4/2/2018 at 3:00 p.m. confirmed that there was no assessment completed by him in Patient #11's medical record. He stated, I may have been remiss about charting my assessment.

Review of the RN nursing note documentation dated 04/06/17 at 7:20 P.M. showed the patient was noted to be alert and oriented to person, place, time and situation. Pt. #11 was noted to be anxious and tachypneic (rapid breathing greater than 20 breaths per minute). Pt. was noted to have an abrasion to his nose, forehead and right side rib. The patient complained of numbness and tingling of his bilateral lower extremities (BLE). Pain was elicited to the BLE with no movement. The patient was rolled off the backboard at this time. At 7:40 P.M., the patient was medicated with 2 mg of Versed (medication used for anesthesia and sedation). At 7:45 P.M., that patient was taken to cat scan (CT) for a scan of the neck and head. Continued review of the medical record failed to reveal the patient's signature on the consent for treatment and patient rights. It was noted on the signature line that the patient was "unable" to sign.

A review of the discharge instructions dated 04/06/17 at 9:40 P.M., provided by the RN, revealed the patient was provided with information on a "cervical strain." This was not noted as a diagnosis by the attending physician that assessed Patient #11. The discharge instructions indicated the patient should seek immediate medical care if numbness, tingling, weakness, or paralysis in any part of the body should occur. Review of the ambulance report assessment revealed the patient could not get up without assist, unable to ambulate, neuro paraplegia to his lower extremities. Prior to discharge patient #11 continued to complain of lower extremity numbness. The patient was unable to ambulate prior to discharge. The discharge note was not signed by the patient and it was noted he refused to sign the document and was argumentative towards staff and resisted bending his legs to get into the wheelchair.

A phone interview on 04/02/18 at 3:15 P.M. with the RN that documented that the patient resisted bending his legs to get into the wheelchair, stated she could not remember who brought the patient from the wheelchair to the car or how he was assisted into the car. The RN stated the patient said he could not move his legs but was actively pushing against her as she was trying to get him into the wheelchair. The RN stated she felt the patient appeared to be a transient with poor hygiene and did not want to leave. She also stated the patient was noncompliant with the discharge instructions and stated the patient said he felt there was something wrong with him. The RN said she told the patient that his CT was negative. She further stated when the patient first arrived he was unable to move his feet but after the CT scan he moved his feet when pain was elicited.

An interview with the Director of Emergency Services confirmed the above findings in the medical record of Pt. #11 on 4/2/18 at approximately 2:45 p.m. for this hospital.

A review of additional medical records revealed that on 04/17/17 Pt. #11 presented to Facility A (another acute care hospital) with complaints of ongoing BLE paralysis and BUE numbness and tingling. A review of the ED physician History & Physical revealed the following focused neurological assessment: patient is unable to stand and unable to move arms above the chest level; motor weakness to both upper extremities. Decreased grip strength, unable to fully flex or extend all fingers. Sensation: numbness, that is severe, of the right hand and left hand. Gait: unable to stand and bear weight. Continued review of the physician note showed the following: MRI supports diagnosis of C4, C5, and C6 cervical spine anterior cords syndrome and patient needs to be transferred to another facility for a higher level of care. Facility B was contacted and the case was discussed with a neuro trauma surgeon. The patient was accepted by the neurology trauma surgeon at facility B due to a spinal cord injury and need for spinal cord decompression.

A review of Facility B's neurology surgery discharge summary dated 05/05/17, showed a principal diagnosis of cervical spinal cord compression and a secondary diagnosis of quadriplegia/quadriparesis.

The facility's policy titled "Medical Screening, Stabilization, and Transfer Criteria EMTALA" Board approval 6/27/2017, Review and Published date 8/13/2018 was reviewed. The policy revealed in part, "II. PURPOSE: To establish guidelines medical screening, stabilization ...All individuals presenting to a Dedicated Emergency Department requesting medical services, and patients arriving /presenting via ambulance requesting medical services shall receive an appropriate medical screening examination and stabilization services as required by the Emergency Medical Treatment and Labor Act ("EMTALA") ...IV. POLICY: A. Medical Screening Examination ...4.The Medical Screening Examination is an ongoing process. The patient's medical record reflects continued on going monitoring, according to the patient's needs and continues until he/she is stabilized or appropriately transferred."


A review of the policy entitled, "Trauma Service Structure Standard V: Emergency Department", with an original effective date of 2/5/2009, a published date of 9/10/2016, a revision date of 1/25/2018 and a reviewed date of 02/22/2018, showed D. Resuscitation Area Documentation, 1. The trauma flow sheet will be used to document patient care in the resuscitation area. The flow sheet will be used to document a sequential account of...serial physiological measurements and neurological status.

A review of the policy entitled, "Trauma Service Structure Standard XIV: Spinal Cord Injuries", reviewed 09/09/2016, showed all spinal cord injured patients arriving at Bayfront Health St. Petersburg will be evaluated and stabilized. The ED physician/trauma surgeon will contact an appropriate on-call specialist who will evaluate and provide acute care for the patient.