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Based on review of facility policy, medical record reviews, and interviews, on 10/7/16 Hospital A failed to provide stabilizing treatment for an emergency medical condition for one patient (#3) of 33 Emergency Department (ED) patients reviewed. The facility's failure to provide stabilizing treatment resulted in Patient #3 being discharged home on 10/7/16 at 6:17 PM with diagnosis of Headache and Hypertensive disorder even though his Perfusion Computed Tomography (PCT TCA/x-ray using special equipment which shows details of blood flow in the brain) dated 10/7/16 at 6:06 PM, revealed the patient had an Acute Posterior Circulation Stroke (damaged brain tissue caused by a clotted blood vessel in the brain). The patient was discharged home where his symptoms worsened overnight and he returned to the ED on 10/8/16 at 11:04 AM and was diagnosed with an Acute Cerebrovascular Attack (Stroke). The patient was transferred to Hospital B by ambulance on 10/8/16 at 6:39 PM where a right vertebral artery extraction of clots was performed and a CT scan showed the patient to have acute to subacute infarctions (cellular damage) in the right cerebellum of his brain.


Refer to A-2407 for failure to provide stabilizing treatment.

Based on policy review, record reviews, and interviews, the facility failed to provide stabilizing treatment within the capability of the staff and facilities available at the facility for one patient (#3) of 33 patients reviewed.

The findings included:

Review of facility policy "Emergency Medical Treatment & Active Labor Act," dated January 2014, revealed "...If an individual has an emergency medical condition, further medical examination and treatment as is within the hospital's capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility..."

The facility's policy on "Communication of Critical Results" Effective 06/05, revised date 5/16 and Approval date by CNO 7/16/2017 was reviewed. The policy stated in part, "purpose: To appropriately and efficiently communicate critical test results that may require therapeutic intervention for serious abnormalities ....Definitions: Critical Result, finding that warrant rapid communication ...Policy Statement/Procedure:" I. Critical results of tests and diagnostic procedures can occur for ...Imaging/Radiology ...and other diagnostic testing in any setting in this organization ...Communication of Critical Results: A. All critical test/critical results must be received by the patient's licensed caregiver ...II. Communication and Notification of Ordering Physician: A. Critical Results ... 2. Call page ordering physician ...Outpatient Communication of Cortical Results: C. Emergency Department (ED): 2. For patients that have left the ED refer to the callback Notification and Documentation in the ED policy."

The facility's policy titled "Callback Notification and Documentation in the ED, Effective 4/16 and Approved by: MEC 8/15/2016, was reviewed. The policy revealed in part, "Purpose: To provide guidelines for notification of Emergency Department (ED) patients of finalized test results reported after they have left the ED that require a change in treatment, and for documentation of notification. Policy: Finalized lab and radiology test results reported after the patient's discharge from the ED will be reconciled daily. The ED physician or Mid-Level provider (MLP) on duty will review all the positive results and the treatment and adjust treatment as appropriate. Patients will be contacted by facility designated staff. The notification will on the ...Call Back Notification form and added to the patient's medical record. Procedure: A. Radiology: If a radiological interpretation is not available at the time the Emergency Department physician make a disposition of the patient, the ED physician interpretation will indicated in the medical record. The ED provider will review any positive radiologist interpretation ad make appropriate instructions for further treatment/follow-up as needed. Facility designated staff will contact the patient with further instructions as indicated by the provider ... Callback Procedure: 1. Staff will document all attempts of patient notification on the ... Call back notification form..."

Medical record review revealed Patient #3, according to the "Emergency Sign In Sheet" presented to the Emergency Department (ED) at Hospital A (Parkwest Medical Center) on 10/7/16 at 1:37 p.m., "Primary Reason for visit Today: Possible side effects to medication: extreme headache blurry vision/vertigo (dizziness). Review of the Triage and Nursing History revealed the chart was started at 1:44 PM for complaint of headache. The review revealed the Patient's mode of arrival was listed as "Walked In." Further review revealed the patient was triaged by a registered nurse (RN) on 10/7/16 at 1:44 PM and was triaged at a level "...3 Urgent...[patient] states it this is the worse headache he has ever had...denies history of migraines..." Continued review revealed the patient's blood pressure at 1:44 PM was 186/103 (normal 120/80) and the patient's pain was documented as "...8/10..." (on a scale of 1-10 with 10 being severe pain).

Further review revealed that at 1:45 PM the ED physician examination was started. The physical examination revealed the patient's general presentation was listed as vital signs were reviewed and the patient appeared to be in no acute distress ... Neurologic ...oriented to person, place, and time ...Musculoskeletal: No extremity tenderness.
Review revealed the following medications and nursing procedures were administered by an RN as ordered by the ED physician on 10/7/2016:
- Saline lock established at 2:30 PM
- Sodium Chloride bolus dose 1000 mg given IV at 2:40 PM;
- Morphine injection 2 mg intravenously (IV) for horrible pain (pain scale 8-10) administered at 2:42 PM;
- Zofran (for nausea) 4 mg IV administered at 2:43 PM;
- Morphine injection 2mg administered IV distressing pan (pain sale 6/10 ) at 3:50 PM;
- Oxycodone 5mg/Acetaminophen 325mg administered (discomforting pain (pain scale 4/10) orally at 7:00 PM;
- Clonidine 0.1 orally (treatment of Hypertension) administered at 7:00 PM.

Further review revealed on 10/7/16 at 1:48 PM a Computed Tomography (CT) Scan of the Brain without contrast was ordered and completed at 3:29 PM. Continued review revealed a CTA (CT Scan with Angiogram) was ordered at 3:45 PM and completed at 6:00 PM.

Medical record review of a physician's notes dated 10/7/16 at 6:06 PM revealed "...PCT CTA [Perfusion Computed Tomography (x-ray using special equipment which shows details of blood flow in the brain) scan]...reviewed the radiologist's report for this film. Negative brain imaging study...negative..."

Medical record review of a physician's discharge summary dated 10/7/16 at 6:17 PM revealed "...Primary Diagnosis; Headache Hypertensive disorder...Condition at disposition - stable; Disposition decision is discharge..." Documentation also revealed the patient was discharged with a pain score of 4/10. The patient's discharge method indicated the Patient #3 was with his wife and physically left the ED. There was documentation in the medical record to indicate if the patient required assistance with ambulation prior to discharge. According to an interview with the patient's wife it was reported that at discharge the patient had difficulty walking to and getting into the car on 10/7/2016.

Medical record review of a "Preliminary Radiology Report" dated 10/7/16 at 7:09 PM revealed "...Focal thrombus [blood clot] in the mid right vertebral artery [an artery in the brain] with 50-70% stenosis [narrowing]. Sequelae [resulting in] localized [nearby] arterial dissection [a tear in the artery wall] is possible...Focal occlusive thrombus or embolus [a mass, such as an air bubble, a detached blood clot, or a foreign body, that travels through the bloodstream and lodges so as to obstruct or occlude a blood vessel] in the basilar artery [an artery that supplies the brain with oxygen rich blood] at the superior cerebral artery origins. Both superior cerebellar arteries have occlusions with..." The comment section the Negative revealed in part, "Comment: Negative CT today CT does not exclude acute infarct. Addendum: I called the CT technologist (name listed) who is confirming the receipt of the preliminary report by the patient's nurse 7:09 PM." (Further review of the report revealed it was faxed to Hospital A's ER by the radiology department on 10/7/16 at 7:11 PM. There was no documentation in the medical record to indicate that Patient #3 and or wife were notified of the critical results of the radiology report dated 10/7/2016. The facility failed to ensure that their policy and procedure was followed as evidenced failing to have a designated person contact Patient #3 with further instructions from the provider as stated in their policy status post discharge form the hospital on 10/7/2016.


Medical record revealed the patient was discharged and left the ED on 10/7/16 at 7:16 PM.

Medical record review revealed the patient returned to the ED at Hospital A on 10/8/16 at 11:03 AM via ambulance for complaint of headache.

Medical record review of a triage note dated 10/8/16 at 11:04 AM revealed "...Patient was seen in this ER for headache and had a normal head CT...Patients wife states he has been vomiting since last night and pain in his head has increased..."

Medical record review of a Nurse's Note dated 10/8/16 at 12:30 PM revealed "...Patient crying in stretcher...Patient not verbalizing to wife at this time...Only nods yes or no and holding up fingers...to answer yes or no..."

Medical record review of a physician's notes dated 10/8/16 at 4:00 PM revealed "...Reviewed CT today, CT yest [yesterday] and CTA yesterday. CTA with Thrombus Right Vertebral Artery. Occlusive Thrombus/embolus basilar artery...Primary Diagnosis Posterior Circulation Stroke [damaged brain tissue caused by a clotted blood vessel in the brain]..."

Medical record review of a physician's order dated 10/8/16 at 5:00 PM revealed "...Transfer to [Hospital B] dx [diagnosis] acute cerebellar CVA [Cardiovascular Attack/Stroke]...condition serious/guarded...consult neurosurgery on arrival...increased risk cerebellar edema...acute cerebellar cva right..."

Medical record review revealed the patient was transferred from Hospital A to Hospital B by ambulance on 10/8/16 at 6:39 PM.

Medical record review of a physician's history and physical, from Hospital B, dated 10/8/16 at 9:06 PM revealed "...was transferred to [Hospital B] this evening from [Hospital A] for suffering an embolic CVA...He decided to go to [Hospital A] emergency department on 10/7/2016. CTA of the head and neck was performed which read focal thrombus of the mid right vertebral with 50-70% sequela of localized arterial dissection possible focal occlusive thrombus in the bibasilar artery at the superior cerebellar artery origins both cerebellar arteries have occlusions...Unfortunately the patient was sent home at that time with diagnosis of headache...the patient was felt best to be transferred to the stroke center here at [Hospital B]...given the fact the patient has had symptomatology greater than the time frame for TPA [tissue plasma activator medication used to dissolve and remove a blood clot from a blood vessel]. He is not a candidate [for TPA treatment]...the patient has decompensated [symptoms have worsened] during the initial interview that I saw him here in the emergency department at [Hospital B] at 1955 [7:55 PM] at 2030 [8:30 PM] has progressed to the point where he has lost control and grip of the right upper extremity and has decreased movement to the right lower extremity...CTA of the head and neck obtained yesterday reveals focal thrombus of the mid right vertebral with 50-70% sequela of localized arterial dissection possible focal occlusive thrombus in the bibasilar artery at the superior cerebellar artery origins both cerebellar arteries have occlusions...Acute thrombotic cerebrovascular accident..."

Medical record review of a discharge summary, from Hospital B, dated 10/13/16 revealed the patient was admitted with diagnosis of Acute ischemic Stroke in the Right Vertebral Artery, Right Hemiplegia (weakness and paralysis), and Dysarthria (difficult and/or unclear speech). Further review revealed "...Interventional radiology performed right vertebral artery extraction of clots and also left recanalization of the basilar artery and right middle cerebral artery status post clot extraction...CT scan of the brain performed without contrast after the interventional procedure which showed acute to subacute infarctions [cellular damage] in the right cerebellum...the patient regained some function of the right leg. The right arm still had hemiplegia...He will be transferred to [rehabilitation hospital]..." Further review revealed the patient was discharged to a rehabilitation hospital on 10/13/16 for continued Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST).

Telephone interview with Patient #3's wife on 7/13/17 at 11:00 AM revealed the patient was having "the worse headache in his life" along with dizziness and loss of balance beginning the morning of 10/7/16. Continued interview revealed the patient and his wife went to the ED at Hospital A in the afternoon of 10/7/16 and was seen by a physician who appeared very concerned regarding the patient's symptoms and recommended a CT Scan and a CTA with contrast and if those were negative he recommended a lumbar puncture. Further interview revealed the patient remained in severe pain until he was given his second dose of morphine in the ED, after which his symptoms began to improve slightly. Continued interview revealed the CTA with contrast was performed at approximately 6:00 PM and the ED physician came into the room at approximately 6:10 PM and told her and the patient the "...CTA was negative and we are 96% certain that there is nothing to be concerned about..." Further interview revealed the physician offered to perform a lumbar puncture but did not recommend it. Continued interview revealed the patient was given a prescription for pain medication and a prescription for blood pressure medication and discharged from the ED at approximately 7:15 PM. Further interview revealed the patient was unsteady and needed support from her to walk to their car and the patient was severely nauseated and vomited for approximately 10 minutes before he could enter the car. Continued interview revealed the patient remained in severe pain and was extremely nauseated with frequent vomiting all night on 10/7/16 and at approximately 8:00 AM on 10/8/16 the patient was slumped over in the bed, was unable to sit up, and had a noticeable "...droop to the right side of his face..." Further interview revealed the wife called Emergency Medical Services (EMS) and while waiting the patient fell onto the floor and remained on the floor until the first responders arrived. Continued interview revealed the patient was taken by EMS to Hospital A at approximately 10:40 AM and by this time the patient was unable to speak and was unable to move his right arm or leg. Further interview revealed the patient was eventually seen by another physician who told the wife he was going to order a lumbar puncture, but the patient's wife (following the recommendations of a nurse practitioner friend) requested a repeat CTA be performed and the physician ordered a CTA based on the wife's request. Continued interview revealed the patient was taken for the CT at approximately 2:30 PM and the physician came to the room at approximately 3:30 PM and told her and the patient "...the CTA today showed evidence of damage and there was a stroke..." Further interview revealed "...the physician admitted the CT yesterday did show something and it was misread..." Continued interview revealed the patient was not provided any treatment and eventually was transferred to Hospital B at approximately 6:30 PM, where he was quickly taken for surgical removal of the clot. Further interview revealed the patient's condition deteriorated all day on 10/8/16 and after the surgery he continued to be unable to move his right arm and leg, he was unable to swallow, had a feeding tube placed, was unable to speak, and he was incontinent. Continued interview revealed the patient was discharged to a rehabilitation hospital for continued rehabilitation on 10/13/16, where he remained for 3 weeks, and the patient currently has weakness, limited use in his right arm and leg, difficulty with speech, and incontinence.

Interview with the ED Supervisor on 7/10/17 at 2:00 PM, in an administrative office, revealed Patient #3 came to the ED at Hospital A on 10/7/16 for a complaint of a headache. Further interview revealed a CT and a CTA scan was performed, but the patient was discharged before the results were sent to the ED. Further interview revealed the patient returned to the ED on 10/8/17 with increased headache and neurologic deficits and was transferred to Hospital B. Continued interview confirmed Hospital A had teleneurology (access to neurology services via internet/computer contact) services available on 10/7/16, which were not provided for this patient.

Interview with Hospital A's Senior Risk Manager (SRM) on 7/12/17 at 10:20 AM, in an administrative office, confirmed the physician notes documented the PCT CTA results were negative on 10/7/16 at 6:06 PM. Further interview confirmed the PCT CTA results were interpreted by radiology at 7:09 PM and faxed to the facility on 10/7/16 at 7:11PM.

Interview with Physician #3, a Neurology Hospitalist at Hospital A, on 7/12/17 at 11:10 AM, in an administrative office, revealed Physician #3 was not involved in the care of Patient #3, but based on his review of the radiology reports Patient #3 "...definitely needed hospitalization..." Further interview revealed the physician believed the patient needed additional diagnostic tests and depending on the test results, may have needed vascular interventions to remove the clot obstructing the blood vessels.