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Based on medical record review, interviews and policy review, the facility failed to provide an appropriate medical screening examination that was within the hospital's capability for Patient #15 and #20 who presented to the emergency department with stroke symptoms. The cumulative effect of this systemic practice is a risk to all patients presenting to the emergency department.

Findings include:

See A2406

Based on medical record review, interviews and policy review, the facility failed to provide an appropriate medical screening examination for two patients who presented to the emergency department with stroke symptoms (Patient #15 and #20) of 20 medical records reviewed. The emergency department's average daily census is 125.

Findings include:

1. The medical record review for Patient #20 was completed on 05/30/13. The patient arrived by ambulance to the Emergency Department (ED) on 11/20/12 at 1:46 AM. The ED Notes at 1:48 AM revealed the patient complained of right sided weakness and was unable to recall his/her birthday.

At 1:53 AM Patient #20 told staff his/her head "hurts pretty good ." An electrocardiogram was completed at 1:55 AM. The notes revealed the patient could not move the right arm or right leg on command, although, moves the right hand to the face. The patient's blood pressure was 153/81 at 1:57 AM. The neurological exam at 2:04 AM revealed the patient was alert and oriented X 4, has difficulty following commands and has episodes of slurred speech and has been unable to rate headache pain by number. At 2:07 AM the patient was seen by the physician. The patient was discharged from the ED to home.

On 05/29/13, Staff K (nurse manager) of the emergency department provided a copy of signs and symptoms of stroke. The signs and symptoms were:
-language disturbance
- altered perception
- visual change
-dizziness and/or vertigo
- speech slurring
-weakness (arms or legs)
- numbness
- gait disturbance
-acute severe headache
-facial drooping

There was no documentation in the medical record for Patient #20 that revealed the hospital followed their policy titled "Code Stroke Alert Activation and Response" dated 03/11/13. The policy directs the hospital staff to activate the code stroke alert on all patients who present with stroke symtom onset within less than seven hours. When a patient has been identified as experiencing acute stroke symptoms, the emergency department registered nurse will utilize the emergency department Triage CVA/TIA electronic orders to activate a Code Stroke Alert. There was no evidence that this protocol was used for Patient #20 on first admission to the ED.

Patient #20 returned to the ED on 11/20/12 at 8:38 AM. The ED notes at 8:39 AM revealed the patient still had tingling to right leg and was now having difficulty moving extremity. At 8:40 AM the patient's blood pressure was 97/64 and the patient rated headache pain as 9 with 10 being the worst pain. At 9:32 AM the patient was ordered to receive a CT of the head. At 10:40 AM the CT order was canceled. At 10:44 AM an order for CT of the head was again ordered. At 12:03 PM the patient was admitted to the Intensive Care Unit for Intracranial Bleed. At 1:07 PM the patient was still complaining of tingling to the right arm and leg although was able to move them.

2. The medical record review for Patient #15 was completed on 05/30/13. The patient was brought to the emergency department via paramedics on 05/16/13. The ambulance run sheet revealed documentation Patient #15 complained of numbness in the right foot and headache. The patient arrived at 3:00 PM. The triage nurse assigned the patient as a level 4. Review of the triage policy titled " Triage and Triage Acutity Classification" dated January 1, 2013, revealed the use of the emergency severity index listed below:
Level 1 patient requiring immediate lifesaving intervention
Level 2 patient presenting with high risk situation, or confused, or lethargic, or severe pain or distress.
Level 3 patient requiring two or more resources, and/or abnormal vital signs.
Level 4 patient requiring one resource, which may include but is not limited to: "stable without life/organ threat. Physician would be delayed, low resource intensity. Requires simple diagnostic or procedures. Anticipate one resource."
Level 5 requiring no resources.

The patient was placed back in the waiting room in a wheelchair. The emergency department notes stated that at 4:23 PM, a family member of another patient in the lobby yelled for the triage nurse. The triage nurse observed the patient leaning forward in the wheelchair about to fall on the floor. The registered nurse pushed the patient back into the wheelchair to prevent a fall or injury. The registered nurse tried to call for assistance with no response. The registered nurse left the patient with a service advocacy staff and went to obtain help for the patient. The registered nurse returned to the lobby and found the patient face down on the lobby floor. The patient was placed in a C-collar and on a backboard. The patient was transported to room 8. At 4:25 PM, Staff G documented the patient stated his/her leg feels "dead", is able to move the leg with no assistance, that Patient 15 stated his/her left foot feels numb and that was the reason for coming to the ED.

There was no documentation in the medical record for Patient #15 that revealed the hospital followed their policy titled "Code Stroke Alert Activation and Response" dated 03/11/13. The policy directs the hospital staff to activate the code stroke alert on all patients who present with stroke symtom onset within less than seven hours. When a patient has been identified as experiencing acute stroke symptoms, the emergency department registered nurse will utilize the emergency department Triage CVA/TIA electronic orders to activate a Code Stroke Alert. There was no evidence that this protocol was used for Patient #20 on first admission to the ED.

At 4:40 PM, Staff G documented the patient was very drowsy, had intermittent movements of her legs and arms and the patient stated she thought people were punching her. The nurse also noted the patient slept until 2:00 PM on 05/16/13. At 4:46 PM, Staff G documented the patient will wake up at times and ask for pain medications, stated she is in a lot of pain and she has a migraine headache.

A Computerized Tomography Scan (CT Scan) was ordered at 4:57 PM. At 5:00 PM, Staff G documented the patient had muscle spasms to the left arm when the patient's blood pressure was taken, had intermittent muscle spasms in legs and the patient stated he/she is hurting all over. Staff G took the patient for the CT Scan at 5:05 PM. At 5:23 PM, Staff G documented the patient had sluggish right and left pupil reactions.

At 8:27 PM, the emergency room physician ordered the patient be admitted to the hospital. At 9:24 PM, Staff G documented the patient as drowsy, oriented X 4 and with brisk pupil reaction to bilateral eyes. At 10:07 PM the patient stated he/she felt like he/she had been poisoned by mosquitoes. At 10:09 PM, Staff G documented the patient continues to complain of left leg numbness, at times just lets it flop, but when asked, patient is able to move it and support the left lower extremity with no difficulty. Staff G wrote the patient rates pain level at a nine out of ten for back and head. The patient was transferred to an inpatient floor at 11:33 PM. The inpatient floor nurse documented the patient arrived to the floor and reported being "paralyzed" on left side. The patient had only partial grip with the left hand when the nurse asked the patient to grip his/her hands.

The physician who evaluated the patient after admission documented on 05/17/13 the patient presented to the emergency department with a head ache and mental status changes and patient reported left side upper and lower extremity weakness and cannot move them at all. The physician assessed the patient and documented a pain level of four out of five in left upper extremity and a zero out of five in left lower extremity. The physician wrote he/she was worried about cerebrovascular accident; patient's thrombocytosis puts patient at risk.


On 05/17/13, the patient was transferred to a different facility for treatment. On 05/18/13, a neurologist documented an MRI confirmed multiple infarcts primarily in the left MCA territory and one in ACA. This suggests that the etiology is likely artery to artery thrombis or cardioembolic. Vessel imaging inadequate. The neurologist diagnosed the patient with hemiparesis and altered mental status.