HospitalInspections.org

Based on medical record review, facility policy and protocol review, review of on-call schedules, and interview, the facility failed to maintain a list of on-call physicians, failed to provide stabilizing treatment, and failed to provide appropriate transfer for one patient (#9) of twenty sampled patients reviewed.

The findings included:

Please refer to A-2404 for failing to maintain a physician on-call list
Please refer to A-2407 for failing to provide stabilizing treatment
Please refer to A-2409 for failing to provide apporpriate transfer

Based on review of facility policy, review of Emergency Room On-Call Schedules, observation, and interview, the facility failed to maintain a list of on-call neurologists.

The findings included:

Review of facility Policy Number PC-07179 most recently reviewed and/or revised in September 2009, and titled "EMTALA (Emergency Medical Treatment and Labor Act) Guidelines - Treatment and Transfer of Individuals in Need of Emergency Medical Services revealed, "...The Hospital shall maintain an on-call list of physicians, including specialists and sub-specialists who are available to examine and treat an individual with an emergency medical condition...The Medical Staff Office, on a monthly basis, creates the Emergency Department ("ED") on-call Roster...the ED will maintain the on-call rosters...The on-call roster is divided into categories of medical specialties...specialties include but are not limited to...Neurology..."

Review of Emergency Room On-Call Schedules dated January-July 2012, revealed no documentation regarding on-call neurologists.

Observation on August 21, 2012, at 4:47 p.m. at an Emergency Room nurse's station, revealed a list of on-call physicians that identified the specialty, and included a physician's name and telephone number. Continued review revealed the specialties included neurology with a telephone number, and no documentation regarding identification of an on-call neurologist.

Telephone interview with Registered Nurse (RN) #1 on August 23, 2012, at 2:40 p.m., revealed the On-Call Schedule for August 23, 2012, included a phone number to call when neurology was required. RN #1 stated, "...If (a) patient (is) under the care of a neurologist we call their neurologist, otherwise we just call this answering service..."

Based on review of facility policy and protocol, medical record review and interview, the facility failed to provide stabilizing treatment for one patient (#9) of twenty sampled patients.

The findings included:

Review of facility Policy Number PC-07179 most recently reviewed and/or revised in September 2009, and titled "EMTALA (Emergency Medical Treatment and Labor Act) Guidelines - Treatment and Transfer of Individuals in Need of Emergency Medical Services revealed, "...The Hospital will provide an individual with an emergency medical condition such further examination and treatment as required to stablize the emergency medical condition, within the capability of the Hospital...To stabilize...mean...the patient is provided such medical treatment of the condition as is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient..."

Review of facility Policy Number ECC-01070 and most recently reviewed and/or revised in January 2010, revealed, "...Title Standard of Care - CVA (Cerebrovascular Accident) or Stroke...Outcome: To establish guidelines in the treatment of a CVA/Stroke patient...A patient who arrives at the Emergency Center with CVA or stroke may receive the following care...Notify Emergency physician to determine if patient meets criteria for thrombolytic (dissolution of blood clots) therapy..."

Review of an Emergency Center Protocol For t-PA (tissue plasminogen activator - dissolves clots and restores blood flow) In Acute Stroke dated August, 2006, revealed, "...NOTIFY on call Neurologist of potential t-PA candidate...Review the following exclusion criteria...Are the patient's stroke symptoms greater than 3 hours old? (IV(intravenous) t-PA must be given within 3 hours of onset of stroke symptoms...Does the CT (Computerized Tomography) brain demonstrate intracranial bleed or mass effect...Screening ER (Emergency Room) Physician Signature If the answer to any of the above questions is 'YES', the patient is not a candidate for t-PA...If the answer to all the above questions is 'NO', the patient may be a candidate for t-PA...NOTIFY Neurologist that patient IS a t-PA candidate..."


Patient #9 presented to Hospital #1's Emergency Department on March 26, 2012.

Medical record review of Patient Information revealed, "...Arrival Date/Time: 1213 (12:13 p.m.)...Stated Complaint: Neurologic Symptoms/Deficits..."

Medical record review of a Triage Assessment dated March 26, 2012, at 12:23 pm., revealed, "Stated Complaint: Possible Stroke...onset SOB (shortness of breath) after walking to surgery waiting...family reports slurred speech...High Risk Situation..."

Medical record review of a nurse's note dated March 26, 2012, at 12:47 p.m., revealed, "...reassessed in triage. Noted to have reoccurence of slurred speech. Equal grip strengths. L (left) side facial droop." Medical record review of a nurse's note dated March 26, 2012, at 12:51 p.m., revealed, "...taken to room...(Medical Doctor - MD #1) notified of pt (patient) change in status."

Medical record review of an untimed Emergency Department Physical History and Assessment dated March 26, 2012, revealed, "Chief complaint: slurring...duration less than one hour...with L facial droop that has waxed and waned...decreased blink on Left..."

Medical record review of a CT (computerized tomography) scan of the brain without contrast dated March 26, 2012, at 2:33 p.m., revealed, "...Impression...No acute intracranial abnormality..."

Medical record review of a nurse's note dated March 26, 2012, at 4:02 p.m., revealed, "Dramatic neuro (neurological) changes noted...increased slurred speech and left sided weakness...(M.D. #1) notified, (M.D. #1) to bedside @ (at) (4:03 p.m.)..."

Medical record review of the Physical History and Assessment dated March 26, 2012, revealed, "...Disposition Discussed with pt and family. Pt dysarthria seems more prounounced and I am uncertain of Bell's Palsy...Discussed with (neurologist) who requests MRI. If negative D/C (discharge) with steroids)...(4:00 p.m.)...densely hemiplegic on L. Call (neurologist)...onset greater than 3 hours. Recommended (Hospital #2)..."

Medical record review revealed no documentation regarding an ER Center Protocol for t-PA in Acute Stroke for Patient #9. Medical record review revealed no documentation regarding assessment by a neurologist.

Medical record review of a Certificate of Transfer dated March 26, 2012, revealed, "...Diagnosis: Neurological deficits with L side neglect...The patient has been stabilized within reasonable medical care standards. No further deterioration is likely as a result of transfer..."

Medical record review of a CT scan of the brain with and without contrast dated March 26, 2012, at 5:05 p.m., revealed, "...Comparison is made with previous...exam (examination) of the brain dated 3/26/2012...There is a questionable minimal developing infarct in the anterior limb of the right internal capsule...Impression...Occlusion of the right internal carotid artery and proximal portion of the right middle cerebral artery...Questionable minimal infarct in the anterior limb of the right internal capsule..."

Medical record review revealed the patient was transferred to Hospital #2 on March 26, 2012.

Medical record review of an Emergency Room Record (Hospital #2) dated March 26, 2012, revealed, "...Triage (6:19 p.m.)...presented to ed (Emergency Department) with complaints of stroke like symptoms transfer from (Hospital #1)...onset of new symptoms app (approximately) 45 minutes...Arrived via (Hospital #1's) EMS (emergency medical service)...(6:38 p.m.)...Historian: History obtained from patient, records from transferring facility. Time course: Onset of symptoms reported as sudden..." Medical record review of a physician's progress note dated March 26, 2012, at 6:52 p.m., revealed, "...Patient's status is critical."

Medical record review of a physician's progress note dated March 26, 2012, at 6:52 p.m., revealed, "...pt had neg Head CT for acute bleed, no surgery, no head bleed per pt. reviewed risk and benefits pt wants to go with tPa. Spoke with (M.D. #2) ok to give tPA..." Medical record review of a physician's progress note dated March 26, 2012, at 6:54 p.m., revealed, "Review of transfer records..." Medical record review of a physician's progress note dated March 26, 2012, at 7:11p.m., revealed, "...pt unchanged. will continue with tPA waiting for neuro eval (evaluation)."

Medical record review of a physician's progress note dated March 26, 2012, at 7:27 p.m., revealed, "spoke with (M.D. #2)...states after talking with family, stroke started this am (a.m.). I spoke with patient who said symptoms started at 5 pm (p.m.) and EMS hand over indicated that symptoms started at 4 pm. Family was not here yet so that is the information I went with. tPA was stopped..."

Medical record review of the medical records sent by Hospital #1 to Hospital #2 revealed no documentation regarding the final report of the CT scan of the brain dated March 26, 2012, at 2:33 p.m. or the CT scan of the brain dated March 26, 2012, at 5:05 p.m.

Medical record review of a Consultation dated March 26, 2012, revealed, "...was visiting (spouse)...at (Hospital #1)...Per the family, who were present at the time of onset, which was around 11 or 11:30 a.m...started staggering...happened while (Patient #9) was in (Hospital #1)...was immediately taken to the emergency room...apparently had a CT angiogram of head done at (Hospital #1), which showed a distal...occlusion on the right side, and around 5:30 pm...was transferred to us for further management. Because the records from (Hospital #1) indicated that the time of onset was 5:00 p.m...thought to be within the window for...TPA...I stopped the TPA infusion...Assessment...Acute ischemic stroke secondary to internal carotid artery occlusion....Left hemiplegia left hemi neglect, secondary to stroke...Admit to ICU (intensive care unit)..."

Medical record review of a History and Physical dated March 26, 2012, revealed, "...basically had started a TPA infusion and then later discovered...time of onset was different than originally reported, and so that was stopped....has a continued dense left hemiplegia and neglect...continues in ICU (Intensive Care Unit) after receiving part of the TPA dose. Also with a large stroke and risk of hemorrhage..."

Interview with M.D. #1 on August 22, 2012, at 10:28 a.m. in an Emergency Room office in Hospital #1, revealed M.D. #1 was prepared to discharge the patient after consultation with a neurologist and negative findings from a CT of the brain. Continued interview revealed the nursing staff informed M.D. #1 of a decline in the patient's condition, the neurologist was reconsulted and recommended a CT scan of the brain with contrast, and M.D. #1 stated, "...was past the three hour window (a specific timeframe for administration in relation to onset of symptoms) for t-PA and that's why (neurologist) wanted me to call (Hospital #2)."

Interview with the ER Nurse Manager on August 22, 2012, at 11:30 a.m., in a conference room, revealed the ER Nurse Manager was unaware the facility had a stroke protocol. The ER Nurse Manager stated, "...just if we know we're getting a possible stroke we just get them to CT scan right away."

The facility failed to follow their stroke protocols, and failed to treat and stabilize the patient. The patient was misdiagnosed with Bells Palsy and was not evaluated for stroke in a timely manner.

C/O: #30311

Based on review of facility policy, medical record review and interview, the facility failed to ensure an appropriate transfer for one patient (#9) of twenty sampled patients.

The findings included:

Review of facility Policy Number PC-07179 most recently reviewed and/or revised in September 2009, and titled "EMTALA (Emergency Medical Treatment and Labor Act) Guidelines - Treatment and Transfer of Individuals in Need of Emergency Medical Services revealed, "...The Hospital will provide an individual with an emergency medical condition such further examination and treatment...or arrange for transfer of an individual to another medical facility in accordance with the procedures set forth below...'Stable for transfer' means...The physician...determines...that the receiving facility has the capability to manage the emergency medical condition..."



Patient #9 presented to Hospital #1's Emergency Department on March 26, 2012.

Medical record review of Patient Information revealed, "...Arrival Date/Time: 1213 (12:13 p.m.)...Stated Complaint: Neurologic Symptoms/Deficits..."

Medical record review of a Triage Assessment dated March 26, 2012, at 12:23 pm., revealed, "Stated Complaint: Possible Stroke...onset SOB (shortness of breath) after walking to surgery waiting...family reports slurred speech...High Risk Situation..."

Medical record review of a nurse's note dated March 26, 2012, at 12:47 p.m., revealed, "...reassessed in triage. Noted to have reoccurence of slurred speech. Equal grip strengths. L side facial droop." Medical record review of a nurse's note dated March 26, 2012, at 12:51 p.m., revealed, "...taken to room...(Medical Doctor - MD #1) notified of pt (patient) change in status."

Medical record review of an untimed Emergency Department Physical History and Assessment dated March 26, 2012, revealed, "Chief complaint: slurring...duration less than one hour...with L (left) facial droop that has waxed and waned...decreased blink on Left..."

Medical record review of a CT (computerized tomography) scan of the brain without contrast dated March 26, 2012, at 2:33 p.m., revealed, "...Impression...No acute intracranial abnormality..."

Medical record review of a nurse's note dated March 26, 2012, at 4:02 p.m., revealed, "Dramatic neuro (neurological) changes noted...increased slurred speech and left sided weakness...(M.D. #1) notified, (M.D. #1) to bedside @ (at) (4:03 p.m.)..."

Medical record review of the Physical History and Assessment dated March 26, 2012, revealed, "...Disposition Discussed with pt (patient) and family pt dysarthria seems more prounounced and I am uncertain of Bell's Palsy...Discussed with (neurologist) who requests MRI. If negative D/C (discharge) with steroids)...(4:00 p.m.)...densely hemiplegic on L. Call (neurologist)...onset greater than 3 hours. Recommended (Hospital #2)..." Continued review revealed no documentation regarding communication with a receiving physician or (Hospital #2).

Medical record review of a Certificate of Transfer dated March 26, 2012, revealed no documentation regarding an authorizing person at (Hospital #2; appropriate medical information sent with the patient; or a Registered Nurse (Hospital #2) to whom report was given. Continued review revealed specific benefits and risks regarding transfer were not documented and included, "...Diagnosis: Neurological deficits with L side neglect...The patient has been stabilized within reasonable medical care standards. No further deterioration is likely as a result of transfer...Date/Time 3/26/12/(4:13 p.m.)...Consent to Transfer...to the service of (M.D. #2) at (Hospital #2)..."

Medical record review of a CT scan of the brain with and without contrast dated March 26, 2012, at 5:05 p.m., revealed, "...Comparison is made with previous...exam (examination) of the brain dated 3/26/2012...There is a questionable minimal developing infarct in the anterior limb of the right internal capsule...Impression...Occlusion of the right internal carotid artery and proximal portion of the right middle cerebral artery...Questionable minimal infarct in the anterior limb of the right internal capsule..."

Medical record review of a nurse's note dated March 26, 2012, at 5:34 p.m., revealed, "...Will prepare pt. for Transfer."

Medical record review revealed no documentation regarding the time or condition of the patient at the time of transfer.

Medical record review of an Emergency Room Record (Hospital #2) dated March 26, 2012, revealed, "...Triage (6:19 p.m.)...presented to ed (Emergency Department) with complaints of stroke like symptoms transfer from (Hospital #1)...onset of new symptoms app (approximately) 45 minutes...Arrived via (Hospital #1's) EMS (emergency medical service)...(6:38 p.m.)...Historian: History obtained from patient, records from transferring facility. Time course: Onset of symptoms reported as sudden..." Medical record review of a physician's progress note dated March 26, 2012, at 6:52 p.m., revealed, "...Patient's status is critical."

Medical record review of a physician's progress note dated March 26, 2012, at 6:52 p.m., revealed, "...pt had neg Head CT for acute bleed, no surgery, no head bleed per pt. reviewed risk and benefits pt wants to go with tPa (tissue plasminogen activator - dissolves clots and restores blood flow). Spoke with (M.D. #2) ok to give tPA..." Medical record review of a physician's progress note dated March 26, 2012, at 6:54 p.m., revealed, "Review of transfer records..." Medical record review of a physician's progress note dated March 26, 2012, at 7:11p.m., revealed, "...pt unchanged. will continue with tPA waiting for neuro eval (evaluation)."

Medical record review of a physician's progress note dated March 26, 2012, at 7:27 p.m., revealed, "spoke with (M.D. #2)...states after talking with family, stroke started this am (a.m.). I spoke with patient who said symptoms started at 5 pm (p.m.) and EMS hand over indicated that symptoms started at 4 pm. Family was not here yet so that is the information I went with. tPA was stopped..."

Medical record review of the medical records sent by Hospital #1 to Hospital #2 revealed no documentation regarding the final report of the CT scan of the brain dated March 26, 2012, at 2:33 p.m. or the CT scan of the brain dated March 26, 2012, at 5:05 p.m.

Medical record review of a Consultation dated March 26, 2012, revealed, "...was visiting (spouse)...at (Hospital #1)...Per the family, who were present at the time of onset, which was around 11 or 11:30 a.m...started staggering...happened while (Patient #9) was in (Hospital #1)...was immediately taken to the emergency room...apparently had a CT angiogram of head done at (Hospital #1), which showed a distal...occlusion on the right side, and around 5:30 pm...was transferred to us for further management. Because the records from (Hospital #1) indicated that the time of onset was 5:00 p.m...thought to be within the window for...TPA...I stopped the TPA infusion...Assessment...Acute ischemic stroke secondary to internal carotid artery occlusion....Left hemiplegia left hemi neglect, secondary to stroke...Admit to ICU (intensive care unit)..."

Medical record review of a History and Physical dated March 26, 2012, revealed, "...basically had started a TPA infusion and then later discovered...time of onset was different than originally reported, and so that was stopped....has a continued dense left hemiplegia and neglect...continues in ICU (Intensive Care Unit) after receiving part of the TPA dose. Also with a large stroke and risk of hemorrhage..."

Interview with M.D. #1 on August 22, 2012, at 10:28 a.m. in an Emergency Room office in Hospital #1, revealed M.D. #1 was prepared to discharge the patient after consultation with a neurologist and negative findings from a CT of the brain. Continued interview revealed the nursing staff informed M.D. #1 of a decline in the patient's condition, the neurologist was reconsulted and recommended a CT scan of the brain with contrast, and M.D. #1 stated, "...was past the three hour window (a specific timeframe for administration in relation to onset of symptoms) for PTA and that's why (neurologist) wanted me to call (Hospital #2)." Continued interview revealed M.D. #1 did not recall communication with Hospital #2 regarding the care of Patient #9 and M.D. #1's communication with an accepting facility was usually documented in the Physical History and Assessment. Continued interview revealed M.D. #1 called the facility's tranfer center (to arrange transfer) and confirmed the facility failed to provide an appropriate transfer for Patient #9. The transfer was not timely for the diagnosis of CVA and it appeared that the facility had the capability to treat the patient. As a result, the patient arrived at Hospital 2 too late for definitive treatment for stroke.

C/O: #30311