HospitalInspections.org

Based on interviews, a review of facility documents, and medical record reviews, staff at the hospital failed to follow policies and procedures governing medical care provided in the emergency department for one of one patient (Patient #1) with stroke-like symptoms.

Findings included:

In an interview at 11:23 a.m. on 7/1/25, staff #3, ED MD reported that during his medical screening exam (MSE) of patient #1 on 5/31/25 at approximately 7:20 p.m., the patient was identified as having stroke-like symptoms that started at 6:15 p.m. Staff #3 determined patient #1 was a candidate for tPA [Tissue plasminogen activator, a fibrinolytic, ex. alteplase - a medication used to dissolve clots in stroke patients.] Staff #3 began the process to transfer patient #1 to Facility B and placed a verbal order for tPA with staff #7, ED RN. Staff #7 reported that they did not have access to tPA in the Emergency Department (ED) and they typically transfer stroke patients to Facility B. Staff #3 stated, "I spoke with everyone there to find tPA." Staff #3 decided the "best thing to do" was to transfer patient #1 "five minutes away rather than wait to find tPA." [Patient #1 was not transferred to facility B until approximately 9:20 p.m.]

In an interview on 7/1/25 at 5:30 pm, staff #7, ED RN reported, "the patient [#1] was complaining of facial numbness, weakness, and had a previous stroke. [Staff #3] wanted to give tPA. I told staff #3 that we always transfer stroke patients to Facility B, which is a stroke center. But I went to the Pyxis [RxStation - a medication dispensing cabinet] and could not find alteplase." Staff #7 called the on-call pharmacist for help. "The pharmacist said we had tPA in the cath [cardiac catherization] lab but only in a 10 mg syringe, which is not the dosage we wanted to give. I also called the CCU [Critical Care Unit] charge nurse, but she could not find it either. It was taking me 15-20 minutes to find the medication, so [staff #3] decided to transfer the patient to Facility B in the interest of time. We were within the time window to administer tPA so we called 911 and had the patient transferred ASAP [as soon as possible]... Normally, we do not give tPA. The medication is unsafe, and we wouldn't be able to monitor the patient for complications, such as hemorrhage... I've administered tPA once in the last 10 years and never at this hospital."

In an interview at 3:30 p.m. on 6/30/25, Staff #8, Director of Pharmacy, stated that on Monday, June 2nd, he was informed that an RN could not find alteplase on the evening of Saturday, May 31st. The on-call pharmacist contacted for assistance could only locate a 10 mg syringe of Activase. On 6/2/25, Staff #8 informed leadership that the medication was available in the Rx Station but was listed under the brand name Activase. Staff must choose either the brand name or the generic name to access medications. Staff #8 has changed the Rx station so that it is listed under the generic name alteplase not the brand name Activase. He acknowledged that this same scenario could re-occur if an RN entered the brand name Activase instead of the generic name alteplase. Staff #8 sent an email to leadership on 6/5/25 with instructions on how to access the medication.

During a tour of the pharmacy on the afternoon of 7/1/2025, Staff #8 was questioned about the Override function on the Rx Station. It was observed that the first screen showed an alphabetical list of medications listing both the brand and generic names. Activase (altepase) did appear on this list. Staff #8 stated that he had manually changed this after the incident on 5/31/25 so that both names appeared. He added that he only had to do this for a few medications, including Activase (alteplase). Staff #8 asked Staff #10, pharmacy buyer, if he had been the one to change the name of Activase to alteplase in the Rx station. Staff #10 stated "No you did it."

In an interview on the afternoon of 7/1/2025 with Staff #10, pharmacy buyer, he was questioned about the override function on the Rx station and whether the alphabetical listing of medications had been changed since the incident on 5/31/25. He replied, "No it's always been that way."

During interviews on the afternoon of 7/1/25, staff #6 and staff #11, ED RNs, were both able to verbalize how to access alteplase and how to use the reference feature [Lexicomp - a database containing information about medical drugs] to access unfamiliar medications. Staff #6 reported he had only administered fibrinolytics [ex. alteplase] once in the last 15 years at this facility and Staff #11 reported he had never given this medication at Facility A.

In an interview at 4 p.m. on 6/30/25, Staff #4, ED Medical Director, reported he has only administered alteplase about 10 times in the last 22 years and stated "[Facility B] is so close ... they could have easily walked that distance." Staff #4 added "the window for administering alteplase from last know well (LKW) is 90 to 120 minutes but we would already have had patients across the street to Facility B."

In an interview on 7/1/25 at 10:22 AM, Staff #1, Director of Quality, reported that no in-services or additional education had been offered to nursing staff after the incident on 5/31/25. Staff #1 also reported that stroke education is part of the annual clinical education and all medical staff are National Institute of Health Stroke Scale (NIHHS) certified.

Review of Documents

A review of facility policy "Activase Administration and Preparation (last reviewed 05/2024)" reveals in part "Activase may be administered to patients according to approved indications for acute stroke ... in the Emergency Department ...."
Facility A has adopted the "Adult Suspected Stroke Algorithm (based on American Heart Association [AHA] 2020 - 2025 guidelines)" as their stroke pathway. In the ED, this algorithm is on a clipboard on the crash cart in Trauma Bay 1. According to the timeline on the algorithm, patients that are a candidate for fibrinolytic therapy should receive tPA within 1 hour after presenting to the ED with stroke-like symptoms.

A review of the of the medical record for patient #1 reveals in part:

ED Provider Documentation by staff #3 on 5/31/25 at 8:07 PM:
History Of Present Illness (HPI): "Patient is a 57-year-old ... with ...History of CVA [Cerebral Vascular Accident] in 2016 ...who presents to The [sic the] ED for concern of left arm numbness. Patient [#1] states that symptoms started [sic at] approximately 6:15 PM, and include left arm numbness, left face numbness, slurred speech... [Patient #1] says that the slurred speech has improved. But still has the sensation deficits in ... left face and left arm.. On reevaluation patient [#1] continued ... to have left upper extremity weakness and decreased sensation to light touch. CT [Computed tomography] head without contrast was ordered and shows no evidence of intracranial bleeding ... Facility B was contacted for transfer. Initial plan was to give tPA prior to transfer. And discussed all of the contraindications with the patient [#1] ... and [Patient #1] ... is a candidate for tPA. However attempted to order the tPA here and spoke with the pharmacist and per their discussion, does not have proper dosing in facility at this time and there would be a time delay in getting proper tPA mixed here. Spoke with Facility B again at approximately 845pm, discussed this with the team, and they recommended immediate transfer as to not delay further care ..."

Addendum by [Staff #3] on May 31, 2025 at 9:29 pm:
"[Facility B] EMS crew picked up the patient and left at approximately 2120 [9:20pm] ...with one hour and 25 min left of the tpa window ..." According to the "Adult Suspected Stroke Algorithm" adopted by Facility A, Patient #1 was outside of the tPA window.