HospitalInspections.org

Based on a review of facility documentation and staff interview, the facility failed to comply with 42 CFR 489.24(a) as the hospital failed to provide an appropriate medical screening examination within its capabilities to 1 of 1 patients (Patient #1) with an emergency medical condition. This resulted in a delay in Patient #1 receiving appropriate and timely medical care to address his emergency medical condition of Guillain-Barre.

Cross refer A-2406 Medical Screening Exam.

Based on a review of facility documentation and staff interviews, the facility failed to provide a timely and appropriate medical screening exam within its capabilities to 1 of 1 patients (Patient #1) with an emergency medical condition for a patient presenting with the signs and symptoms of a Guillain-Barre syndrome (GBS). For a patient complaining of bilateral numbness and tingling of the extremities, the National Institute of Neurological Disorders and Stroke recommended that deep tendon reflexes in the legs, such as knee jerks, should be tested, and this was not performed. "Reflexes may also be absent in the arms. Because the signals traveling along the nerve are slow, a nerve conduction velocity test (NCV, which measures the nerve ' s ability to send a signal) can provide clues to aid the diagnosis. There is a change in the cerebrospinal fluid that bathes the spinal cord and brain in people with GBS. Researchers have found the fluid contains more protein than usual but very few immune cells (measured by white blood cells). Therefore, a physician may decide to perform a spinal tap or lumbar puncture to obtain a sample of spinal fluid to analyze." No lumbar puncture was performed.


Findings were:

Facility policy #BSWH.ADMIN.001.P, entitled "Patient Transfer (EMTALA)," last reviewed 1/26/18 (origination date 11/18/16), included the following:
"DEFINITIONS ...

Emergency Medical Condition - means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance, and symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the health of the individual (or with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;

2. Serious impairment to any bodily functions;

3. Serious dysfunction of any bodily organ or part...


POLICY

The Governing Body, in consultation with the medical staff, has adopted this Policy according to the Federal and state laws and regulations regarding the medical screening examination/evaluation, stabilizing treatment, and Transfer of Patients from a BSWH (Baylor Scott & White Health) medical center to another medical center in a medically appropriate manner ...

Patient Rights

BSWH recognizes the right of an individual to receive, within the capabilities of the medical center's staff and facilities:
-An appropriate medical screening examination ..."


A review of the emergency department record of Patient #1 revealed, he was a 59-year-old male, who presented to the emergency department of this hospital on the morning of 2/20/18 at 11:29 a.m. A triage note listed Patient #1's emergency severity index as a 3. The initial provider encounter was documented as having occurred at 11:30 a.m.

The ED record included the following:

"NEURO SYMPTOMS HPI (History of Present Illness):

-Chief Complaint Details - year-old this morning with tingling hands and feet approximately 5 hours ago. He thought walking around the house would improve this, but it did not. he says his legs also feel heavy He denies any weakness on one side of the other, change in speech, vision, chest pain, SOB, or vertigo. He does feel mildly lightheaded. He has not fallen. He had flu last week and feels better, and finished Tamiflu 5 days ago.

-Presenting Symptoms weakness, paresthesia

-Onset noted on awakening

-Weakness Location left upper extremity, right upper extremity, left lower extremity, right lower extremity

-Cognition alert, oriented to person, oriented to place, oriented to time

-Progression awoke with symptoms

-Gait walks without assistance

-Associated Symptoms [+] nothing specific

-Associated Symptom [-] no fever, no sweating, no chest pain, no vomiting, no visual disturbances, no dizziness, no seizure, no memory loss, no loss of balance, no loss of coordination ..."


REVIEW OF SYSTEMS

-General CONSTITUTIONAL: No fever, No weight loss, no malaise. NEURO: No AMS (altered mental status). No Confusion. No ataxia or focal weakness. EYES: No vision changes. ENT (ear/nose/throat): No voice changes. No stridor. No difficulty swallowing.

CARDIO: No palipitations [sic]. No chest pain, No syncope. No Dizziness. No edema. No Dyspnea at rest.

RESPIRATORY: No SOB or Dyspnea.

GI: No Abd pain. No vomiting. No diarrhea.

GU: No dysuria or hematuria.

SKIN: No rash or ulcerative lesions.

MUSCULOSKELETAL: No swelling.

-Neuro [+] DIZZINESS, PARESTHESIA

-Psych [-] no depression, no insomnia, no memory loss, no mood swings, no visual hallucinations

-Psych [+] ANXIETY

All other systems reviewed and negative, except as noted here and in HPI ..."


A continuation of the record review revealed the following:

"RESULTS INTERPRETATION

Interpretation of Lab Tests No laboratory abnormalities of acute significance ...

TREATMENT PLAN:

-Complaint Specific Differential Diagnosis dehydration, anemia, electrolyte imbalance, anxiety, obstructive sleep apnea, orthostatic hypotension, dysrhythmia..."


Further review of the ED record of Patient #1 revealed:

"ASSESSMENT AND PLAN:

HEALTH ISSUES:
1. Paresthesia of both feet...
2. Paresthesia of both hand...
3. Work stress...
4. Dizziness...
5. Weakness..."


Nursing Notes in the emergency department record of Patient #1 included the following:

11:30 a.m. - "patient c/o bilateral "tingling" of both upper and lower extremities. Patient denies weakness, reports feeling off balance and slightly dizzy when attempting to ambulate. EKG done. patient and family informed of plan of care..."

1:00 p.m. - "Patient laying in bed vital sign stable voiced no concern at this time no need for interventions at this time."

2:12 p.m - "Medication given for dizziness"

2:45 p.m. - "Medications seemed to have helped with dizziness."

3:30 p.m. - "Patient dizziness better but still having weakness in the legs doctor aware."

4:00 p.m. - "CT at bedside to take patient for CT"

5:00 p.m. - "Patient discharged instructions and prescriptions given family at bedside, patient understands instructions and to f/u with neuro and family doctors, patient voiced no concern at this time iv d/cd (discontinued) tip intact."

Patient vital signs on 2/20/18 at 11:41 were as follows: temperature 97.5, heart rate 82, respirations 16, blood pressure 183/111, oxygen saturation on room air 98%.


Review of the patient emergency department record continued:

"Rechecks, Disposition and Transfer of Care:


RECHECKS:

Recheck - Patient stable. Patient deteriorating. s (spouse) with him he understood but felt like he still could not stand well. I offered a CT of the head to clear it of mass or bleeding. He declined the CT and prefers to follow-up.

Recheck - Patient stable. his wife talked him into the CT. He is remained stable since arrival. There just has not been significant improvement after Ativan for anxiety and/or vertigo to relieve his symptoms discharged home without further imaging of his head

Recheck - Patient stable. we discussed CT limitations. In light of the results I recommended the next step would be an MR (magnetic resonance). They both declined, deferring instead to go home and try increased ambulation. He says he feels better when he is walking around and prefers to do that at home.

Recheck - Details

Additional Comments - referral given for [physician name], or [physician name] for sleep study follow-up, and Neuro [physician name]. Rx: diazepam 5mg tid vertigo x 15. Instructions are dizziness, paresthesia, and fall precautions with emphasis on returning for any worsening symptom ..."


The medical screening examination did not include a test of the patient's reflexes. This test is critical in diagnosing Guillain-Barre, and should be checked in a patient complaining of bilateral numbness and tingling of the extremities. The workup also did not include a lumbar puncture.


Discharge information provided to the patient included documents entitled "Dizziness," "Paresthesia," and "Fall Prevention and Home Safety," as well as medication information on diazepam. A final section entitled Additional Notes and Instructions included the following:

"[Physician name] is neurology for dizziness/vertigo/tingling. [Physician name] is family practice for sleep study and testosterone monitoring.

Observe fall precautions, and return for any change or worsening symptoms. If you do return we would just resume where left off which is the MRI that recommended as the next step ..."


A physician emergency department note at another facility later that evening read as follows:

Physician ED Documentation for [Patient #1] from the...emergency department on 2/20/18 at 11:20 p.m. included the following:


"History of Present Illness:

The patient presents with lower extremity, weakness, paresthesia and loss of reflexes. The onset was began this morning. The course/duration of symptoms is worsening. Location: Bilateral lower extremity. The character of symptoms is weakness, altered sensation and tingling. The degree at onset was moderate. The degree at maximum was moderate. The degree at present is moderate. Risk factors consist of recent upper respiratory infection 10 days ago. Prior episodes: none. Therapy today: She [sic] apparently went to an outside facility and was seen and told that his worsening neurologic symptoms were from anxiety and was discharged home. He has rapidly worsened and can no longer ambulate on his own. Associated symptoms: She [sic] denies shortness of breath, chest pain or urinary retention. Baseline status: ambulatory.

Additional history: This morning patient had paresthesias in both feet, but by the time he arrived in the ED he had 2-3 out of 5 strength in the bilateral lower extremities with decreased sensation to light touch and absent reflexes both patellar and Achilles...

Impression and Plan

Diagnosis
Guillain-Barre syndrome ...

Disposition: Admit: Time 02/20/2018 23:28:00 ..."


In a telephone interview with the wife of Patient #1 on the evening of 3/23/18 at 7:17 p.m., she stated, "We were very disappointed that the hospital in Lakeway took the stance that they did and that they had a careless attitude - really careless - when working on my husband. I'm a lot upset by this ...They checked his reflexes and they said that they were not quite right. They also stretched him. And all the time he was very slow at reacting, but they did a check and saw that they were slow. They did a CT scan. We kind of hemmed and hawed, "Do we really need one?" We never said no to it. They did a heart thing and the CT scan. We weren't reluctant - just questioning. Then they wanted to do an MRI. We were wondering why and just asked about it. He just kept getting weaker and weaker...


We were there all day. The doctor never once came in and saw us. We were starting to get a little flustered because we had kids still in school and it was getting to be time to pick them up...The nurse practitioner, was saying, "You have sleep apnea." So we were starting to think he had sleep apnea. I was so flustered the whole visit. And then he just kept getting weaker and weaker. And they gave us a prescription and said, "Go home, take it and get some rest, and tomorrow you can see a neurologist. You can see a sleep expert...I left to go to the pharmacy for a few minutes. I came back and he couldn't move.


...He had to go to the bathroom. So I said, "Let me help you." He'd been lying on the bed for 3 hours. I had to get a male nurse to help me put him on the pot. He couldn't make it. Then that nurse had to go get another male to help get him back to bed - so it took 3 people - me and 2 male nurses - to take him back to the bed.


At this point, we were getting very frustrated. What they had for us after all this time was sleep apnea? They said, "That's the best we can do." So I asked, "What do we do next?" That nurse practitioner said, "You can either go home, get some rest and I can give him a prescription, you can seek a sleep study, or you can seek a neurologist." He couldn't even stand at this point...We wouldn't have had to go to an emergency room if it wasn't an emergency. And it was not a busy day there. I remember seeing one other person in there." Patient #1's wife stated that upon her husband's discharge, she pulled their car up to the main hospital entrance and her husband was brought out via wheelchair to the car.


She stated upon getting home, "I texted [a friend] and said there's something going on with [Patient #1]. I asked if there was any way we could talk to her husband [a neurologist]. I asked if we could talk about [her husband's] symptoms and just maybe get a second opinion. That was maybe 5:30 or 6:00 p.m. He [physician] came directly over. I was out getting the prescription. I was coming back in, and he said to me, "...This is an emergency. This looks like Guillain Barre." I'd never heard of it. I was thinking, "How can he make that assessment so fast? How could he know that?" He said, "We need to get him into the hospital stat." He [Patient #1] hadn't been out of the other hospital maybe even 45 minutes yet. He [neurologist] said, "He needs an ambulance and they need to come now."


He's still in critical care even now. He had a tracheostomy. He's had two bouts of pneumonia. He's had a second round of IV IG. He's in acute critical condition...He was there and got his first round of IV IG. Then [physician's name] said we could start rehab. He was discharged from [other hospital] and at the rehab hospital for 3 days. At that point, he developed his first pneumonia. They put him on life support. He was intubated. He went back to [other hospital] and has been there ever since.

It's been a nightmare."



In an interview with Staff #2, ED physician, on the afternoon of 3/20/18 at 2:50 p.m., in an administrative office, she stated, "This patient came in with paresthesias. We got a CT scan because the symptoms did not resolve. He was offered an MR (magnetic resonance imaging), but declined. In general, with people who come in with dizziness as a chief complaint, we're usually concerned with things like anemia, dehydration, electrolyte deficiencies, cardiac arrhythmias, vertigo or BPPV (benign paroxysmal positional vertigo). We're also thinking about things like stroke with dizziness. He had bilateral paresthesias and that would put a stroke lower down on the differentials (differential diagnoses). A CT scan will show a bleed or large mass, but a posterior stroke or brain stem bleed doesn't show well on a CT scan. An MRI is, first of all, posterior area sensitive. Secondly, it can sometimes take up to 48 hours for a stroke to show up on a CT scan. MRIs are just more sensitive to certain areas - quicker. With [assessment of] reflexes, we'd be concerned about a spinal cord issue. They probably weren't done for that reason. We were thinking more posterior stroke ... I remember talking about the MRI with him [Staff #3, Nurse Practitioner] and they [Patient #1 and wife] didn't want to do it...Dizziness is what we were focusing on. Dizziness just really doesn't associate with Guillain Barre, so we never were thinking along those lines ..."


In an interview with Staff #3, ED Nurse Practitioner, on the afternoon of 3/20/18 at 3:15 p.m. in an administrative office, he stated, "They [Patient #1 and wife] said that he was tingling the whole time he was here. We gave him some Ativan (lorazepam), and he still had his symptoms after the medication we gave him. That's why I pushed for an MRI, but they [Patient #1 and wife] didn't want to do that. They said they just wanted to go home. His wife was real convinced that he was anxious and that's what was going on. We couldn't get the dizziness and weakness to go away. I know he got up to go to the bathroom, but his symptoms just weren't improving. She [wife of Patient #1] had to help him. She had to talk him into the CT ..."


When asked what he meant when he had documented in the patient record "Patient stable," Staff #3 stated, "That means nothing was getting worse. His heart rate was the same. His blood pressure was the same. There was no increase in symptoms. He wasn't throwing up. Basically, it means his status hasn't changed, but he didn't improve otherwise. 'Patient stable' is a click-box that you can click on. But I never felt like his symptoms were explainable or improved ...What I remember seeing with this patient was that he had been getting up and going to the bathroom. They didn't want the MRI and that would have been the next thing we would have done. So that was it. They wanted to go home, so they left. We'd addressed his dizziness at that point, so he had stabilized some. There was nothing else to do. At discharge, I would say his symptoms were controlled but not improved."


In an interview with Staff #4, ED Registered Nurse, on the afternoon of 3/20/18 at 3:41 p.m. in an administrative office, he stated, "I remember him [Patient #1] coming off the Tamiflu and wondering if that was what was causing his symptoms. I helped talk him into a CT scan. I kind of remember they wanted to go home. He was up going to the bathroom. I can't really remember much more about him." When asked if he could recall anything about the patient's status upon discharge or how the patient left, Staff #4 stated, "He was probably wheeled out but I have no recollection." When asked if he remembered or could generally say anything else about Patient #1, he stated, "No, not really."


In an interview with Staff #5, emergency department Medical Director, on the morning of 3/21/18 at 10:45 a.m. in the facility conference room, he stated, "This was a difficult situation. Guillain Barre is pretty rare. And it doesn't present with dizziness. As far as the dizziness goes, we did a CT scan. It was at the MRI - that's where it got hung up. We would have progressed in the diagnosis if that had been done and showed up clear ..."