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Based on record review and interview, Hospital A failed to provide for the transfer of one of one patient (Patient #1) who required specialized services. Patient #1 presented to Hospital A with Hypertensive Emergency, Stroke, and Poorly Controlled Diabetes Mellitus Type 2. Hospital A did not have a neurologist or rehabilitation services available. The patient was admitted to Hospital A's medical telemetry unit and experienced neurological decline within a few hours. There was no evidence that the hospital attempted to transfer the patient. Approximately 52 minutes before Patient #1 left against medical advice in the private family car, her blood pressure was in the hypertensive crisis stage that required emergency interventions. Within 46 minutes of leaving Hospital A, Patient #1 presented to Hospital B and was admitted for stabilization and Rehabilitation.
Cross Refer to A2407 Stabilizing Treatment 489.24(d)(1-3)

Based on record review and interview, Hospital A failed to provide for the transfer of one of one patient (Patient #1). Patient #1 presented to Hospital A with Hypertensive Emergency, Stroke, and Poorly Controlled Diabetes Mellitus Type 2. The patient had left-sided extremity weakness and left facial droop. The patient needed two-staff assistance. Hospital A did not have a neurologist or rehabilitation services available. The patient was admitted to Hospital A's medical telemetry unit. Patient #1 experienced neurological decline within a few hours and began choking on water. Patient #1's family demanded a transfer to a higher level of care where rehabilitation services were offered. There was no evidence that the hospital attempted to transfer the patient. Approximately 52 minutes before Patient #1 left against medical advice in the private car, her blood pressure was in the hypertensive crisis stage that required emergency interventions. Within 46 minutes of leaving Hospital A, Patient #1 presented to Hospital B and was admitted for stabilization and Rehabilitation. During her 23-day rehabilitation, Patient #1 experienced functional improvement in 27 self-care categories. Patient #1 was discharged from Hospital B in stable condition.
Findings included:

Hospital A Emergency Department (ED) Nursing Documentation dated 01/09/16 at 13:18 reflected Patient #1 had decreased left hand strength, weakness in left arm and leg, numbness/tingling in the patient's face, left facial droop, ataxia, and slow rate of speech.

Hospital A Personnel #7's History of Present Illness dated 01/09/16 at 13:37 noted Patient #1 presented with emergently high blood pressure of 251/95 and was in "serious condition." The patient's blood glucose level was 369 mg/dL at that time. The treatment plan included hospital admission, dietary modification, smoking cessation, management of Hypertension, Diabetes, and Dyslipidemia.

Hospital A's CVA or Stroke Policy 03.12 dated 12/2015 reflected the procedure to "follow the procedures and protocols established by NIH [National Institute of Health] ...administer the NIH Stroke Scale to obtain baseline assessment ..."

During an interview on 05/10/16 at 10:35, Hospital A Personnel #3 and #6 denied that a stroke scale assessment was completed during Patient #1's ED or hospital stay as recommended by hospital policy.

Hospital A Initial Nursing Interview dated 01/09/16 at 21:05 reflected Patient #1 arrived to the medical floor on 01/09/16 at 20:00. Nursing Physical Assessment dated 01/09/16 at 20:37 reflected the patient was "voiding without difficulty ...will not ring the call bell for help but attempts to go to the restroom herself."

Hospital A Nursing Notes dated 01/10/16 at 07:00 noted that Patient #1 needed two staff members to transfer to the chair due to her "legs not working ...unable to support own wt [weight] ...marked drooping in left face, slurred speech, abnormal pulling of head to ...[the right] ..."

Hospital A Patient Assessment/Nurse Notes dated 01/10/16 at 07:20 noted Patient #1 "began choking on water." Nursing notes, undated, reflected the patient had "positional nausea" at 10:00, 11:00, 12:00, 13:00, and 14:00.

Hospital A Nursing Notes dated 01/10/16 timed at 13:00 reflected Patient #1's blood pressure was noted to be 204/97 mmHg. Nursing administered blood pressure medication through intraveneous route, placed an anti-nausea patch behind the patient's left ear, removed intravenous access and urinary Foley catheter, discontinued telemetry, and provided adult undergarments before Patient #1 and her family left the hospital against medical advice on 01/10/16 at 13:52.

Hospital B Emergency Department (ED) Nursing Notes dated 01/10/16 at 14:38 reflected that Patient #1 came to Hospital B ED after being diagnosed with a stroke at a different hospital and "...was told that the facility did not have neurology..." The patient had facial droop and left-sided extremity weakness. Patient #1's blood pressure was 178/94 mmHg.

Hospital B Emergency Department Notes dated 01/10/16 at 15:20 reflected Patient #1 reported nausea when lying flat. Patient #1 stated, "It feels like my blood pressure is going to explode."

Hospital B Emergency Department Provider Notes dated 01/10/16 at 15:46 reflected Patient #1 could not move her left arm. The patient had weakness in her left leg, had difficulties swallowing, and complained of neck pain that had started in the morning. Patient #1's blood pressure was 186/91. The patient had an asymmetric smile with left lower facial weakness and her tongue deviated to the left side.

Hospital B Neurovascular Service Discharge Summary dated 01/13/16 at 13:56 noted Patient #1 had been admitted to the hospital's stroke unit with a "right subcortical stroke." The patient was stabilized on medications for her blood pressure and uncontrolled blood sugar levels. Patient #1 was discharged to the rehabilitation unit with "moderately severe disability ...unable to walk without assistance and unable to attend to own bodily needs without assistance."

Hospital B Physical Medicine and Rehabilitation Discharge Summary dated 02/04/16 at 16:30 reflected admission and discharge diagnoses including Cerebral Infarction, Hypertension, Hyperlipidemia, Uncontrolled Diabetes Mellitus Type 2, left-sided weakness, and Dysarthria due to recent stroke. At discharge, Patient #1 experienced functional improvements in 27 self-care categories. The patient reached complete independence in bladder control, walked with minimal assistance, and ate with modified independence. The physical discharge exam reflected a blood pressure of 132/67. Patient #1's motor abilities were "grossly intact." The patient was discharged home in stable condition.

Hospital A Personnel #6 denied on 05/06/16 at 13:40 that a memorandum of transfer (MOT) was initiated for Patient #1.

Hospital A Personnel #3 and #6 stated on 05/06/16 at about 14:15 they did not know why Patient #1 was not transferred to a stroke center.

Hospital A Personnel #7 was interviewed on 05/10/16 at 11:50. He stated that Patient #1's condition had worsened the morning after her admission. Patient #1 was not able to swallow and had become incontinent. The family requested a neurologist but none was available at the hospital. Hospital A Personnel # 7 denied physical therapy was available for Patient #1. Hospital A Personnel #7 was asked to provide documentation regarding attempts of transfer. None was provided.