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Based on interviews, a review of the facility's Emergency Department (ED) Logbook, medical record review, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty-one (21) sampled patients (Patient #1) that presented to Facility #1's ED for an Emergency Medical Condition.

Interviews revealed Patient #1 presented to the ED on 10/14/16 with a complaint of "can't remember" and mental status change. Patient #1 was triaged at 8:19 AM with documented vital signs of: Pulse - 128 (normal range for a person of the patient's age is 64-86) and Blood Pressure - 138/107 (normal range for a person of the patient's age is 120/80-140/90). Interview with Family Friend #2, who was with Patient #1 during the ED visit, revealed Patient #1 was "stuttering," having a difficult time verbalizing his/her concerns, was not oriented to time, was anxious, and "distraught." Patient #1 was evaluated by Physician #2 and ordered a CT (a computerized tomography) scan of the head. Patient #1 did not remove his/her earrings during the CT scan resulting in the findings of the scan revealing "examination limited as patient refused to remove jewelry for the exam. Severe streak artifact is noted as a result." Patient #1 was ordered Atenolol (a medication used to treat high blood pressure) and was discharged at 10:19 AM with documented vital signs of: Pulse - 128 (normal range for a person of the patient's age is 64-86) and Blood Pressure - 169/107 (normal range for a person of the patient's age is 120/80-140/90). Family Friend #2 stated Patient #1's presenting emergency medical condition of being confused and mental status changes were not resolved at the time of discharge from the ED and Patient #1 still could not speak in complete sentences. On 10/14/16 at 9:28 PM Patient #1 presented to Facility #2 with "altered speech." An MRI (magnetic resonance imaging) was conducted and it showed "an acute stroke in the left parietal area of the brain." Patient #1 also presented with a "markedly uncontrolled blood pressure" of 161/103. Patient #1 was admitted to Facility #2 with diagnoses that included acute stroke, expressive aphasia secondary to acute cerebrovascular accident (a stroke limiting the ability to speak), slurred speech, hypertensive urgency, and uncontrolled accelerated hypertension (high blood pressure).

Refer to 42 CFR 489.24 (d)(1-3) Stabilizing Treatment (A2407).

Based on interviews, a review of the facility's Emergency Department (ED) Logbook, medical record review, and review of facility policies, it was determined the facility failed to ensure stabilizing medical treatment was provided for one (1) of twenty-one (21) sampled patients (Patient #1) that presented to Facility #1's ED for an Emergency Medical Condition. Interviews revealed Patient #1 presented to the ED on 10/14/16 with a complaint of "can't remember" and mental status change. Patient #1 was triaged at 8:19 AM with documented vital signs of: Pulse - 128 (normal range for person patients age 64-86) and Blood Pressure - 138/107 (normal range for person patients age 120/80-140/90). Interview with Family Friend #2, who was with Patient #1 during the ED visit, revealed Patient #1 was "stuttering," having a difficult time verbalizing his/her concerns, was not oriented to time, was anxious, and "distraught." Patient #1 was evaluated by Physician #2 on 10/14/16 and the physician ordered a CT (a computerized tomography) scan of the head. However, Patient #1 did not remove his/her earrings during the CT scan resulting in the findings of the scan revealing "examination limited as patient refused to remove jewelry for the exam. Severe streak artifact is noted as a result." Patient #1 was ordered Atenolol (a medication used to treat high blood pressure) and was discharged at 10:19 AM with documented vital signs of: Pulse - 128 (normal range for a person of the patient's age is 120/80-140/90) and Blood Pressure - 169/107 (normal range for a person of the patient's age is 120/80-140/90). Family Friend #2 stated Patient #1's presenting emergency medical condition of being confused and mental status changes were not resolved at the time of discharge from the ED and Patient #1 still could not speak in complete sentences. On 10/14/16 at 9:28 PM Patient #1 presented to Facility #2 with "altered speech." An MRI (magnetic resonance imaging) was conducted and it showed "an acute stroke in the left parietal area of the brain." Patient #1 also presented with a blood pressure "markedly uncontrolled" of 161/103. Patient #1 was admitted to Facility #2 with diagnoses that included acute stroke, expressive aphasia secondary to acute cerebrovascular accident (a stroke limiting the ability to speak), slurred speech, hypertensive urgency, and uncontrolled accelerated hypertension (high blood pressure).

The findings include:

Review of the facility's policy titled, "Treatment and Transfer of Individuals who Request Emergency Medical Services," dated 10/28/14, revealed the facility would provide a medical screening examination by a physician or other qualified medical person to any individual who comes to the Emergency Department seeking an examination or medical treatment to determine if the individual has an emergency medical condition. Continued review of the policy revealed if an individual is determined to have an emergency medical condition, the facility would provide the individual further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the facility, or arrange transfer of the individual to another medical facility.

Review of the facility's policy titled, "Stroke Alert Policy," dated June 2013, revealed it was the facility's purpose to provide standardized care in a timely manner for patients that present to the Emergency Department or that are inpatient status exhibiting stroke symptoms. Nurses with appropriate training would immediately upon witnessing any signs and symptoms of stroke in a patient implement the stroke alert process.

Review of the American Heart Association/American Stroke Association literature revealed the signs/symptoms of a stroke are weakness of face, arm, leg, especially on one side of the body; confusion, trouble speaking or understanding speech, trouble seeing in one or both eyes; trouble walking, dizziness, or loss of coordination; and severe headache with no known cause.

Review of the ED Logbook revealed Patient #1 presented on 10/14/16 at 8:19 AM with a chief complaint of "can't remember." Continued review of the Logbook revealed Patient #1 was discharged on 10/14/16 at 10:19 AM with a disposition of "home."

Review of Patient #1's medical record revealed the facility admitted the patient to the ED on 10/14/16 with a chief complaint of "can't remember" and mental status change. Continued review of the record revealed at 8:19 AM, Registered Nurse (RN) #2 triaged Patient #1 and documented vital signs of: Pulse - 128 (normal range for a person of the patient's age is 64-86) and Blood Pressure - 138/107 (normal range for a person of the patient's age is 120/80-140/90). Further review of the medical record revealed an "Uninfuse head CT" report for "memory loss and amnesia" that stated, "Examination is limited as patient refused to remove jewelry for the exam. Severe Streak Artifact is noted as a result." In addition, Physician #2 documented "CT head: negative" and diagnosed Patient #1 with Anxiety Disorder and Disorganized Thought Process. RN #3 documented vital signs upon discharge at 10:19 AM of: Pulse - 128 (normal range for a person of the patient's age is 64-86) and Blood Pressure - 169/107 (normal range for a person of the patient's age is 120/80-140/90). Patient #1 was discharged home with a prescription for Atenolol (a medication used to treat high blood pressure).

Interview with RN #2 on 10/25/16 at 9:34 AM revealed she was working as the triage nurse on 10/14/16 when Patient #1 presented to Facility #1's ED. RN #2 stated Patient #1 was very "upset" and at one point handed her a cell phone so she could speak with Family Friend #1 to help her ascertain Patient #1's chief complaint. RN #2 stated Patient #1 did inform her that "[he/she] could not remember how to work the microwave" and that was very disturbing to the patient. RN #2 stated Patient #1 was not presenting with any symptoms of a stroke other than the difficulty articulating what he/she needed; therefore, she did not implement the "stroke protocol." Continued interview with RN #2 revealed that Patient #1 was distraught over the death of a family member and was very anxious. RN #2 stated she triaged Patient #1 and placed the patient in an exam room and she had no more contact with the patient.

Interview with RN #3 on 10/25/16 at 10:28 AM revealed that she was working in the ED on 10/14/16 and was Patient #1's nurse while he/she was a patient in the ED. RN #3 stated that Patient #1 was "very upset" over the death of a family member and having a difficult time organizing his/her thoughts. RN #3 stated Patient #1 did communicate to her that he/she was not taking his/her prescribed blood pressure medication, had not slept for days, and had been having problems with his/her thoughts/memory and speech for two (2) to three (3) days. RN #3 stated that she did not implement the stroke protocol because she did not feel Patient #1 was having "stroke like" symptoms. RN #3 stated the facility had treated Patient #1's blood pressure problem and had given the patient a prescription for discharge and felt this was an appropriate plan for Patient #1 even though the patient's blood pressure was still high.

Interview with Physician #1 on 10/25/16 at 9:20 AM revealed he was the Radiologist that read the CT scan for Patient #1 on 10/14/16. Physician #1 stated that jewelry makes a streak artifact and it degrades the image and reduces the sensitivity of the scan. In addition, Physician #1 stated that a patient wearing jewelry "could make it so you miss something on a scan that might show up on another scan as a stroke reading."

Interview with CT Technician #1 on 10/25/16 at 10:40 AM revealed he was the CT Technician that conducted Patient #1's CT scan. CT Technician #1 stated that Patient #1 had numerous earrings in each ear, "like ten hoops on each side," that the patient would not remove when asked. CT Technician #1 stated he handed Patient #1 an emesis basin to put the earrings in and the patient "smiled at me" and handed it back. Further interview revealed that he did not recall Patient #1 speaking "much" or being "disagreeable" during the scan.

Interview with Family Friend #1 on 10/24/16 at 5:00 PM revealed that she was on the phone with Patient #1 when the patient first presented to the ED at Facility #1 on 10/14/16. Family Friend #1 stated that Patient #1 was "stuttering and having a difficult time speaking." Continued interview revealed that Patient #1 handed the phone to RN #2 and she told RN #2 that Patient #1 had a death in the family and that he/she could not remember how to do things and did not remember the date. Family Friend #1 stated that when she arrived at the ED, Patient #1 had already been taken for the CT scan and no one told her that Patient #1 refused to remove his/her earrings during the scan. Family Friend #1stated that Patient #1 was still upset and stuttering in his/her speech when Facility #1 discharged the patient from the ED and the patient's blood pressure was "extremely high." Family Friend #1 stated Patient #1's speech became worse and it got so that Patient #1 could not speak. Family Friend #1 stated Patient #1 was taken to Facility #2 where they told the patient he/she had a stroke and they admitted the patient to Facility #2.

Interview with Physician #2 on 10/25/16 at 12:45 PM revealed he was Patient #1's attending physician on 10/14/16 when the patient was in the ED at Facility #1. Physician #2 stated Patient #1 had come to the ED and informed him that he/she was having difficulty remembering "simple things," was not sleeping, and had not been taking medication for his/her high blood pressure. Physician #2 stated he ordered laboratory studies and a CT scan of Patient #1's head to rule out any neurological issues (possible stroke) with Patient #1. Physician #2 stated he reviewed the CT report and did note that Patient #1 kept his/her jewelry on during the scan, but felt that the findings were "negative." Physician #2 stated he prescribed Patient #1 Atenolol (a medication used to treat high blood pressure), discharged the patient home, and instructed the patient to find a primary care physician. Physician #2 stated he felt the patient's blood pressure issue was treated and could be monitored on an out-patient basis and considered the patient stable to discharge.

Interview with Family Friend #2 on 10/24/16 at 3:00 PM and 10/26/16 at 4:00 PM revealed Patient #1 is currently (12 days after the visit to Facility #1) living with the patient's mother, unable to drive, and participating in speech therapy. Family Friend #2 stated that Patient #1 can have limited conversation, but becomes frustrated easily and becomes difficult to understand.

Review of the medical record from Facility #2 revealed Patient #1 presented to the ED at Facility #2 on 10/14/16 with complaints of "trouble pronouncing words and getting mixed up, having slurred speech." Magnetic Resonance Imaging (MRI) was ordered and Patient #1 was diagnosed with an acute cerebral infarction in the parietal lobe, expressive aphasia secondary to cerebrovascular accident, hypertensive urgency, and uncontrolled accelerated hypertension. Patient #1 was admitted to the facility for care and treatment. Facility #2 discharged Patient #1 on 10/18/16.