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Based on document review and staff interview, it was determined that the Hospital failed compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. See A-2406

2. The Hospital failed to ensure stabilizing treatment was performed. See A-2407.

Based on a document review staff interview, it was determined for 1 of 20 patients (Pt #1) presenting to the emergency department (ED) the hospital failed to ensure the patient was documented in the ED central log. This has the potential to affect all patients receiving care in an ED that treats approximately 65 patients a day.

Finding include:

1. The Emergency Department Log from 12/01/22 thru 12/31/22 was reviewed. There was no evidence that Pt #1 was ever registered or placed on the ED tracking log.

2. An interview was conducted with Patient Access Registrar (E #4). E #4 did not recall the situation but answered questions related to the process for registering a pt in a similar situation. E #4 stated, "If a family member states pt is unable to get out of car and is a possible stroke, we call STAT[immediately] over the phone. RN [Registered Nurse] will get patient and then we will register at the bedside. The RN will put the patient in the computer." When asked if a family member and pt leave (if staff are busy and unable to get pt out of the car), how is the pt logged, E #4 stated, "the patient and representative have to present to the desk to input into the system. If they leave, I do not put them in."

3. An interview was conducted with Interim Director of Quality (E #5) on 02/15/22 at approximately 2:45 PM. E #5 confirmed Pt #1 was not on the ED log and stated, "I don't see that patient has ever been here at this hospital. Every patient that presents to the ED should be placed in the computer. We have some re-education to do."

A. Based on document review and staff interview, it was determined that in 2 of 20 (Pt #1 and Pt #16) Emergency Department (ED) records reviewed, the Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided an appropriate medical screening examination. This has the potential to affect all patients receiving care in an ED that treats approximately 65 patients a day.

Findings include:

1. Pt #1's outside record (ambulance run report and receiving hospital Emergency Room (ED) record) was reviewed throughout the survey.

- Video recordings from 12/17/2022 were viewed with the Interim Director of Quality (E #5) and ED Director (E #6). The cameras show the following:

The ED waiting room camera, ED waiting room #2 camera and ED Admitting camera showed:
3:36 PM - A female walked into the waiting room to the registration desk. The female speaks to staff and then walks back out.
3:40 PM - same female walked back in, hesitated in the middle of the lobby. The female appeared to be speaking to staff and then continued to the registration desk. The female speaks to staff again, raises her hands and then walked back out at 3:41 PM.

The ED Parking North Camera Showed:
3:42 - female comes out of the ED entrance door and stands on the sidewalk for approximately 15 seconds.
3:43 - female gets back into the van. The van backs out and turns right out of the parking lot.
3:43 (approximately 15 seconds later, and approximately 7 minutes after the female first presented) - 2 staff members (ED RN/E #7 and RN #8 confirmed by E #6) walk out of ambulance doors with a wheelchair. Staff look around and then return to hospital approximately 40 seconds later.
3:57 PM - black van pulls back into the parking lot.

- The ambulance run report indicated the EMS(Emergency Medical System) call was received at 3:48 PM. The ambulance arrived at the hospital at 3:53 PM. The "Narrative Notes" stated, "(ambulance) was dispatched to the parking lot of (Hospital #1) for a female possibly having a stroke ... EMS finds the patient in the passenger seat of the vehicle crying. Sister, who is the driver of the vehicle, states she tried three times to get (hospital #1) staff to come out to the vehicle to get her sister inside but no one came to help. Sister states around 2 PM today her and the patient were talking and suddenly the pt became unable to speak. Assessment is performed. Pt acknowledges EMS presence and is able to follow commands. When asked questions, pt is only able to mumble incomprehensible sounds ..." The ambulance was in route to (Hospital #2) at 4:04 PM and arrived at 4:22 PM.

- The "ED Provider Notes" from Hospital #2 stated, " ... HPI (History of Present Illness) 62-year-old female .... Presents to the ED by EMS as a code stroke due to acute onset aphasia (unable to speak) and dysarthria (difficulty speaking). Last known well at 2:00 PM today. She was reportedly with a friend when the symptoms began ... the rest of the history and ROS (review of symptoms) is limited due to the patient's severe dysarthria and aphasia. Per EMS, the patient and her friend had driven immediately after the onset to (Hospital #1) and they were having difficulty getting seen at that facility so EMS was contacted and she was brought to (Hospital #2) accounting for the delay in presentation from onset of symptoms .... ED Course: ... 4:43 PM CT (Computerized Tomography) scans negative for an acute hemorrhage (bleeding in the brain), will administer TNK (Tenecteplase - blood clot busting medication) ... 4:50 PM: Pt admitted to the neuro critical care service ... ED Final Diagnosis and Discharge Information: 1. Cerebrovascular accident (CVA - stroke) ... "

- An interview was conducted with ED RN (E #7). E #7 stated, "I'm just speculating that they paged for assistance needed in the parking lot. Myself and another RN (Registered Nurse) went outside and looked around. There was nobody in the vicinity. If a patient has altered mental status or suspected a stroke, we take the pt straight to CT. We obtain the basic information from pt if possible. If pt unable then we will try to get information from family or friend."

- E #5 agreed Pt #1 did not receive a medical screening exam. E #5 stated, "every patient that presents to the ED should receive a medical screening exam . We have some re-education to do."

2. Pt #16's clinical record was reviewed on 02/15/23 at approximately 11:30 AM with E # 6. Pt #16 presented to the ED on 12/18/22 at 10:32 PM with a chief complaint of "Chest Pain." Pt #16 was triaged at 10:37 PM and assigned an ESI (Emergency Severity Index) of 2 (high level of acuity). Chest pain protocol (including lab work, cardiac monitor, oxygen, and continuous pulse oximetry) was ordered at 12:13 AM by ED RN. A nursing note at 2:12 AM, stated "Patient was discovered to have eloped when the physician attempted to see (Pt #1)." The record lacked a MSE (Medical Screening Exam).

- An interview was conducted with E #6 during the record review. E #6 confirmed Pt #16 did not receive a medical screening exam and should have.

3.. The policy titled "Emergency Department Registration and Collections Policy (revised 09/2022)" was reviewed on 02/15/23 at approximately 12:00 PM. The policy stated, " ... Minimum Guidelines for Compliance 1. Patients will be triaged and receive a MSE (triage is not medical screening) ...When a patient leaves the ED before receiving a MSE: If the patient informs the ED registration staff that he/she is leaving the hospital without receiving a MSE, this should be documented .... If the patient has not provided registration information before he/she leaves, the facility should register that patient as John Doe or Jane Doe."

Melton, Linda S.

B. Based on document review and staff interview, it was determined in 2 of 20 (Pt #18, Pt #19) patients presenting to the Emergency Department (ED), the Hospital failed to perform a complete Medical Screening Exam, to include reassessment until transfer to a higher level of care per hospital policy. This has the potential to affect all patients receiving care in the ED that treats approximately 65 patients a day.

Findings include:

1. On 2/15/2023 at approximately 10:00 AM, the clinical record of Pt #18 was reviewed. Pt #18 presented to the ED on 12/16/2023 at 9:58 AM with a chief complaint of "sign and symptoms of stroke since Tuesday morning (3 days prior)." Assessment indicated "weakness in right arm/leg. Gait is unsteady. Speech is slurred. Facial droop on right. Numbness in right leg arm and right leg." Vitals signs on admission were 182/95 blood pressure 71 pulse 15 respirations 98.1 temperature 95% oxygenation on room air. Emergency Severity Index (ESI) level 2.(indicates a high level of acuity). At 11:05 AM a bolus of 0.9 Normal Saline of 1000 milliliter (ml) intravenous (IV) and 5 units regular insulin was administered IV. At 12:20 PM, Pt #18 had a computerized tomography (CT) scan of the head and neck. Pt 18's record on 12/16/2023 at 10:33 AM stated, "Certified Medical Emergency: Patient's condition represents a certified medical emergency." Pt #18 was transferred at 3:45 PM by ambulance to a higher level of care with the diagnosis of Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery - Carotid artery stenosis. Pt #18's clinical record lacked reassessment of the patients physical condition, response to medications given and and lacked reassessment of the patient's vital signs.

2. On 2/15/2022 at approximately 12:30 PM, the clinical record of Pt #19 was reviewed. Pt #19 presented to the ED on 12 /28/2022 at 10:32 AM with a chief complaint of "lost vision in left eye and blood pressure high." Vital signs on admission were 149/67 blood pressure 102 pulse 20 respirations 98.1 temperature 98% oxygenation on room air. ESI level 2. Pt #19 had a CT scan of the head at 11:15 AM. At 12:04 PM a bolus of 0.9 Normal Saline of 2000 ml IV was administered. Pt #19's record on 12/28/2022 at 1:10 PM stated, "Certified Medical Emergency: Patient's condition represents a certified medical emergency." Pt #19 was transferred at 1:12 PM by ambulance to a higher level of care with the diagnosis of Transient cerebral ischemic attack, unspecified. Pt #19's clinical record lacked reassessment of the patients physical condition, response to medications given and lacked reassessment of the patient's vital signs.

3. On 2/15/2023 at approximately 11:30 AM, the Hospital Policy titled "Assessment and Reassessment of Patients"
(revised 6/2015) was reviewed. The policy required, "II. Procedure: J. Patient reassessment will be done in a time frame appropriate for the patient's condition, 2. Category II (Semi-Emergent) - Condition requires expeditious treatment. These patients have potential threat of loss of life, organ, limb or vision...Reassessment may be performed every 30 minutes. K. ...nurses should utilize continuing notes on the appropriate patients to assure aspects of assessment and care are adequately documented. M. In addition, vital sign (blood pressure, pulse, respirations, pulse ox, and temperature should be monitored as follows: 2. Vital signs should be taken at least every 15-30 minutes if patient has been administered medication that affects the homodynamic status, or as indicated by the type of medication administered (excluding temperature). 4. Vital signs will be taken on all patients upon discharge."

4. On 2/15/2023 at approximately 1:00 PM, an interview was conducted with the ED Director (E #6). E #6 reviewed Pt #18 and Pt #19's clinical record. E #6 confirmed both records lacked documentation of the required 15-30 minute vitals based on the ESI score of 2, the discharge vital, and failed to document the reassessment of the patient's condition as required by policy.