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Based on interviews and records review, the facility failed to follow its own policy to ensure 1 of 1 Emergency Department (ED) patients who presented with a potential stroke had required documentation when there was a refusal of treatment. (Patient # 5).

This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency Department.

Findings include:

Review of ED notes revealed that Patient #5 was a 75 year old male, who presented to the Emergency Department of this hospital on 09/28/2014 at 5:46 p.m. with complaints of a syncope episode. Patient #5 was given an Acuity level of Urgent. He had a history of Cerebrovascular accident (CVA), seizures, hypertension, high cholesterol, Alzheimer's and dementia. The patient was screened for a possible stroke.

The following vital signs were recorded during the visit:

At 6:01 p.m., 137/70 blood pressure; 64 pulse; 18 respirations; 97.5 temperature; and 96% oxygen saturation.

At 6:46 p.m., 122/64 blood pressure; 70 pulse; 18 respirations; 97.6 temperature; and 97% oxygen saturation.

At 9:08 p.m., 172/97 blood pressure; 89 pulse; 20 respirations; 98.6 temperature; and 100% oxygen saturation.

According to physician documentation timed 8:46 p.m., counseling was done with the patient and/or guardian. A part of the counseling was a refusal of service. The patient/guardian displays adequate decision making capability and despite a detailed discussion of alternatives, benefits, risks, and consequences refuses: admission to the hospital for further work-up and treatment.

There was no form for against medical advice on the chart to indicate all of this.

At 9:10 p.m., Patient #5 left the ED.

There was no documentation of what was done about the elevation in blood pressure prior to discharge.

During an interview on 01/06/2015, after 2:00 p.m., Staff #3 confirmed the Against Medical Advice should have been completed (AMA) for refusal of treatment.

During an interview on 01/06/2015, at 4:40 p.m., Staff #5 (ED charge nurse) revealed they triage stroke patients within the first 5 minutes and the physician is in immediately. Staff #5 revealed they had a written stroke protocol they followed and went to the nurse's station to check for it. She returned and revealed there was not a stroke protocol. She just knows what to do because she had been a nurse for a long time.

During an interview after 4:40 p.m., Staff #3 confirmed there was no written stroke protocol for the staff.

Review of policies revealed the following:

Policy titled "Assessment of the ED Patient" revised 02/2012

All patients admitted to the Emergency Department will have the following documentation:

Initial vital signs

Additional vital signs shall be obtained depending on patent's condition;

Critical patients every 5-15 minutes, as needed;

Intermediate every 1 hour.

All other patients every 2 hours or prior to discharge;

Response to medication

Condition prior to discharge.


Policy titled "LL.026, EMTALA- Medical Screening and Treatment of Emergency Medical Conditions"

vi. Special Circumstances: Withdrawal of Request of Examination.

1. If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should:

a. Offer the patient further medical examination and treatment as may be required to identify and stabilize an Emergency Medical Condition;

b.Inform the patient of the benefits or the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment ; and

c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and /treatment. The form should contain a description of risk discussed and the examination and/or treatment that was refused.

Based on interviews and records review, the facility failed to:

A. ensure 5 of 5 Emergency Department (ED) patients who presented with potential strokes received thorough and continual nursing assessments and timely medical screening. The facility failed to have written guidelines or policies available for staff to use when stroke patients presented to the ED (Patient #s' 1, 5, 20, 21, and 22).
Refer to A-tag 1101 for additional information.

Based on interviews and records review, the facility failed to ensure 5 of 5 Emergency Department (ED) patients who presented with potential strokes received thorough and continual nursing assessments and timely medical screening. The facility failed to have written guidelines or policies available for staff to use when stroke patients presented to the ED (Patient #s' 1, 5, 20, 21, and 22).

This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency Department.

Findings include:

Review of ED notes revealed that Patient #21 was a 63 year old male, who presented on 01/05/2015 at 11:08 a.m. . Patient #21 presented with a sudden onset of right posterior head and neck pain and was given an acuity level of Urgent.

Review of vital signs, ED notes and the medication administration record revealed the following:

11:11 a.m., blood pressure 197/89; pulse 95; respiration 20; temperature 98.2; pulse oximeter 96%; and pain 9/10 (0 being no pain and 10 being severe pain).

11:24 a.m., the pain agent Toradol 60 milligrams was administered intramuscularly.

12:15 p.m. (over an hour after documentation of first vital signs) the blood pressure was 196/97

12:30 p.m., transfer ordered to an acute care hospital. The diagnosis given to Patient #21 was subarachnoid hemorrhage (stroke).

12:34 p.m. blood pressure 165/91

12:36 p.m. pulse 101, respirations 16 and temperature 96.8

12:43 p.m. blood pressure 151/87

12:47 p.m. the patient left the ED (transferred to another hospital).

There was no documentation of continual assessment of all the vital signs and pain level and there was no follow-up after administration of pain medication.

During an interview on 01/06/2015, after 2:00 p.m., Staff #3 confirmed the problems with assessment and documentation.


Review of the ED notes revealed that Patient #22 was a 49 year old female, who presented on 12/13/2014 at 5:45 p.m.. Patient #22 presented with altered mental status was given an acuity level of Urgent. Patient #22 had diagnoses which included cerebrovascular accident, altered mental status, and Rhabdomyolysis.

Review of the physician documentation revealed the medical screening was initiated at 6:30 p.m. (45 minutes after presenting).

Review of the ED notes revealed that the first documented vital signs at 6:34 p.m. (over 45 minutes after presenting), blood pressure 127/74; pulse 116; respiration 24; temperature 99.0; pulse oximeter 96%.

Review of documentation on the physician screening at 6:57 p.m. Patient #22 had abnormal lab results, urine drug screen, urinalysis, and cardiac labs.

Review of ED notes revealed that the next set of vital signs was at 7:30 p.m., blood pressure 123/78; pulse 130; respiration 20; temperature 99.0; and pulse oximeter 98%. Again at 7:30 p.m., blood pressure 137/62; pulse 114; respiration 20; temperature 99.0; pulse oximeter 98%;

At 9:10 p.m. the patient left the ED (transported to another hospital).

There were no other documented monitoring of vital signs after 7:30 p.m. and prior to discharge at 9:10 p.m..

Review of arterial blood gas results on Patient #22 revealed a collection date of 12/14/2014 at 5:53 a.m... The results were out of range and the patient was discharged on 12/13/2014.

During an interview on 01/06/2015, after 2:00 p.m., Staff #3 confirmed the problems with assessment and documentation. Staff #3 also confirmed the ABG date and time was inaccurate and the medical screening for potential stroke victims should be immediately upon arrival to the ED.

During an interview on 01/06/2015, at 4:40 p.m., Staff #5 (ED charge nurse) revealed they triaged stroke patients within the first 5 minutes and the physician is in immediately. Staff #5 revealed they had a written stroke protocol they followed and she left and went to the nurse's station to check for it. She returned and revealed there was not a stroke protocol. She just knows what to do because she had been a nurse for a long time. During an interview after 4:40 p.m., Staff #3 confirmed there was no written stroke protocol for the staff.


Review of the ED notes revealed that Patient #20 was a 67 year old female, who presented on 11/30/2014 at 1:06 p.m. with a diagnosis of CVA (Stroke) non -hemorrhagic.

The nursing triage assessment was documented at starting at 1:29 p.m. and the patient was given an acuity level of Urgent. The patient complained of the right side of her mouth drooping. The onset of the symptoms occurred 3 hours before presentation.

The first set of vital signs documented on the patient #20 was at 1:37 p.m. (31 minutes after presenting) and at 1:51 p.m.(45 minutes after presenting) there was documentation of the initiation of the medical screening.

At 2:03 p.m., Patient #20 was taken for a computed tomography scan.

At 2:11 p.m., the physician documented the symptoms started 1.5 hours ago which was a discrepancy in what nursing documented.

At 2:35 p.m. there was documentation that the doctor had been in the room and confirmed a stroke with the family. Patient and family approached with possibility of TPA (tissue plasminogen activator) for stroke protocol.

The first documented treatment was at 2:58 p.m. with anti-coagulant medication Activase (should be initiated within 3 hours of start of symptoms).

Review of discharge information revealed the patient left the ED at 3:46 p.m. (transferred to another hospital).

During an interview on 01/06/2015, at 4:40 p.m., Staff #5 (ED charge nurse) revealed they triaged stroke patients within the first 5 minutes and the physician is in immediately. Staff #5 revealed they had a written stroke protocol they followed and she left and went to the nurse's station to check for it. She returned and revealed there was not a stroke protocol. She just knows what to do because she had been a nurse for a long time. During an interview after 4:40 p.m., Staff #3 confirmed there was no written stroke protocol for the staff.


Review of ED notes revealed that Patient #5 was a 75 year old male, who presented on 09/28/2014, at 5:46 p.m. with complaints of a syncope episode. Patient #5 was given an Acuity level of Urgent. He had a history of diagnoses which included CVA, seizures, hypertension, high cholesterol, Alzheimer's and dementia.

The following vital signs were recorded during the visit:

At 6:01 p.m., 137/70 blood pressure; 64 pulse; 18 respirations; 97.5 temperature; and 96% oxygen saturation.

At 6:46 p.m., 122/64 blood pressure; 70 pulse; 18 respirations; 97.6 temperature; and 97% oxygen saturation.

At 9:08 p.m., 172/97 blood pressure; 89 pulse; 20 respirations; 98.6 temperature; and 100% oxygen saturation.

According to physician documentation timed 8:46 p.m., counseling was done with the patient and /or guardian. A part of the counseling was a refusal of service. The patient/guardian displays adequate decision making capability and despite a detailed discussion of alternatives, benefits, risks, and consequences refuses: admission to the hospital for further work-up and treatment.

There was no form for against medical advice on the chart to indicate all of this.

At 9:10 p.m., Patient #5 left the ED.

There was no documentation of what was done about the elevation in blood pressure at 9:08 p.m. prior to discharge.


Review of ED notes revealed that Patient #1 was a 54 year old female, who presented on 08/01/2014, at 8:41 a.m. with complaints of an elevated blood pressure. Patient #1 had an acuity level of Urgent.

Review of vital signs and medication administration revealed the following about blood pressures:

8:53 a.m., blood pressure 183/87;

9:14 a.m. the anti-hypertensive agent Clonidine was administered;

10:05 a.m., blood pressure 125/67;

10:51 a.m., blood pressure 107/60;

11:03 a.m., blood pressure 136/76;

Review of the discharge section revealed at 11:03 a.m. the patient left the ED.

Review of the ED notes revealed at 5:12 p.m. (6 hours after discharge) staff documented the follow-up information on the medication administration. There was documentation that there was no adverse reaction and that the blood pressure was lowered.

During an interview on 01/06/2015, after 2:00 p.m., Staff #3 confirmed the problems with assessment and documentation. The medical screening for potential stroke victims should be immediately upon arrival to the ED.

During an interview on 01/06/2015, at 4:40 p.m., Staff #5 (ED charge nurse) revealed they triaged stroke patients within the first 5 minutes and the physician is in immediately. Staff #5 revealed they had a written stroke protocol they followed and she left and went to the nurse's station to check for it. She returned and revealed there was not a stroke protocol. She just knows what to do because she had been a nurse for a long time.

During an interview after 4:40 p.m., Staff #3 confirmed there was no written stroke protocol for the staff.

Review of policies revealed the following:

Policy titled "Assessment of the ED Patient" revised 02/2012

All patients admitted to the Emergency Department will have the following documentation:

Initial vital signs

Additional vital signs shall be obtained depending on patent's condition;

Critical patients every 5-15 minutes, as needed; Intermediate every 1 hour.

All other patients every 2 hours or prior to discharge;
Response to medication
Condition prior to discharge.

Policy titled "LL.026, EMTALA- Medical Screening and Treatment of Emergency Medical Conditions"

vi. Special Circumstances: Withdrawal of Request of Examiniation.

1.If a patient withdraws his or her request for examination or treatment, an appropriately trained individual from the emergency department staff should discuss the medical issues related to a voluntary withdrawal. In the discussion, the emergency department staff member should:

a.Offer the patient further medical examination and treatment as may be required to identify and stabilize an Emergency Medical Condition;

b.Inform the patient of the benefits or the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment ; and

c. Use reasonable efforts to get the patient to sign a form indicating that the patient has refused the recommended examination and /treatment. The form should contain a description of risk discussed and the examination and/or treatment that was refused.