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Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically, the medical screening exam, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

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A-2406 Failure to provide an appropriate medical screening exam

Based on interview and record review, the facility failed to provide an appropriate medical screening exam for 1 (P-1) of 29 patients reviewed resulting in the potential for an untreated emergency medical condition and poor outcomes. Findings include:

On 6/5/2024 at 1432, review of the medical record for P-1, the patient of concern, revealed there were three encounters in three calendar days the patient was seen at the facility. The first encounter was on 1/23/2024 at 0745 when the 59-year-old male with a history of aortic valve replacement arrived via ambulance with a chief complaint of weakness with nausea and vomiting. Symptoms had started "last night", and he explained he had a loss of motor function in which he felt he could not move. He reported a "mild frontal headache", but denied fever, chills, a stiff neck, cough, shortness of breath, abdominal pain and diarrhea. Physician notes dated 1/23/2024 indicated it was difficult to obtain a history from P-1 due to his "nausea and malaise."

Physical exam revealed no acute neurologic abnormalities. He was described as "alert and oriented x3 (person, place, time)."

P-1 received intravenous fluids and anti-nausea medications. Physician notes dated 1/23/2024 stated the nausea resolved; however, the patient continued to complain of "a nagging frontal headache." "He had no focal neurologic deficits. He ambulated and used his phone well. He complained of weakness. He was refusing to answer most questions and was somewhat confrontational. I am not sure of the reason for his nausea and vomiting... He complains of an inability to ambulate but obviously ambulates well ... He has no neurologic findings on exam but he is not that cooperative. He does not need head CT. He has had many CTs in the past and none had serious pathology ..."

P-1 was diagnosed with "Nausea/Vomiting Adult Patient." Prescriptions for nausea and vomiting were given. Instructions were provided to drink plenty of fluids to keep hydrated and to return if feeling worse.

A nursing reassessment note on 1/23/2024 at 1000 stated, "Patient is refusing to leave room. States he is having a stroke. Patient is not showing any signs or symptoms that would allude to such ...Provider is aware. Patient refuses to walk, but (sic) is able to use his phone and text but will say that he cannot [walk] ... (P-1) refuses to respond and continues to yell at staff. Security has been called. patient (sic) called 911." There was no security report regarding this incident. P-1 was discharged 1/23/2024 at 1009.

P-1 returned to the ED the same night, 1/23/2024 at 1922 with a chief complaint of vomiting and dizziness. Physician notes dated 1/23/2024 revealed P-1 stated since yesterday it felt like "the room is spinning" when he is ambulating he feels like his "head is cloudy". He reported the headache he had earlier in the day had resolved. Physician Staff M documented, "Based on history and physical exam, I am most concerned for peripheral etiology to his vertiginous (vertigo-dizziness)" and described that recent labs were normal and that Physician M did "not believe he requires imaging at this time." He continues to have no focal neurological deficits (sic)."

P-1 was discharged home and instructions were provided to follow up with his family doctor within the next 3 days and to avoid alcohol until his symptoms resolve. He was also given "strict return precautions" for any development of focal neurological deficits. Prescriptions were given for Meclizine and Zofran. He was discharged home 1/23/2024 at 2033.

P-1 returned for a third visit on 1/26/2024 at 1107 with a chief complaint of headache and weakness. He stated his symptoms started Tuesday (1/23/2024). Following discharge on 1/23/2024 he stated he had tried to return to school but was unable to write notes in class, noting issues with his right hand, but not the left. He also continued to complain of muscle weakness and feeling "uncoordinated" when walking. He was described as being agitated and anxious.

A CT (computerized tomography-"cat scan") was obtained and showed "cerebellar infarcts (a type of stroke impacting the cerebellum, responsible primarily for balance) which were not present on imaging of 12/6/2023. The stroke team was activated. Recommendations were given by the stroke team to have a CT angiogram and to transfer to another acute care facility for a higher level of care "due to a risk of swelling." P-1 was transferred via ambulance to another hospital approximately 95 miles away on 1/26/2024 at 1925.

On 6/6/2024 at 1000, a grievance dated 2/15/2024 from P-1 regarding his treatment and care was provided. He told Patient Relations Staff Q he "presented to the ED with the chief complaint of a stroke. He reports the nurse and provider treated him poorly and would not listen to him ...they acted like he was lying and did not take him seriously. He feels that they were treating him like he was 'some alcoholic or something ' because he is native American. He reports that nurse was rude and uncaring, telling him that he needed to leave despite him expressing continued concerns that he was having a stroke. He reports that he had to contact law enforcement because he was being kicked out ... He reports that they were also concerned and offered to take him to the tribal clinic ... He reports returning to the ED later that day and reporting to them that he was still experiencing neurological deficits and felt that he was having a stroke. Pt requesting imaging during both visits to rule out stroke and it was refused. Returned for a third visit, imaging completed and stroke was identified..."

The hospital conducted an investigation and determined there were no concerns regarding the care received by P-1 on any of his encounters.

Available hospital capabilities at the time of P-1's first two ED visits included advanced imaging (including CT), an on-call stroke neurology physician, and examination capabilities to evaluate P-1's functional status (including assessment of gait, vestibular function, and ability to tolerate oral intake).

Based on interviews and review of hospital policies, on-call schedules, and capabilities, the hospital failed to provide an appropriate medical screening examination for P-1 during two ED visits within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed.