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Based on interview, record review and review of the facility's policies and procedures, it was determined the facility failed to ensure compliance with 489.24 relating to its failure to provide an appropriate medical screening examination, failure to provide stabilizing treatment and the hospital inappropriately delayed treatment for one (1) of twenty (20) sampled patients.

Based on record review and interview, it was determined the facility failed to provide an appropriate medical screening examination by failing to properly evaluate hypertension and cervical spine fractures.

Findings include:

Interview with the Director of Nursing (DON) at the Nursing Home, on 05/16/16 at 2:17 PM, revealed on 04/26/16 Patient #1 had sustained a fall. Patient #1 received a Computed Tomography (CT) scan (used a computer processed X-Ray to produce images of specific areas scanned which allows the user to see inside the human body without cutting). Hospital #1 deemed Patient #1 was ok to discharge to the Nursing Home with a high blood pressure (BP) (normal BP 120/80 Lippincott) The DON stated Patient #1 was a dialysis patient and his/her blood pressure had never been high. The DON stated the nursing home conducted Neurological checks and Patient #1's blood pressure continued to go up to 200/100 which was double Patient #1's baseline. The DON stated Patient #1 was at the Nursing Home for about two (2) hours before the Nursing Home transferred Patient #1 back to Hospital #1. Hospital #1 then completed another CT scan of the head and administered a blood pressure medication. Hospital #1 then sent Patient #1 back to the Nursing Home. The DON stated the Medical Director of the Nursing Home, intervened in the parking lot and gave the order to send Patient #1 to Hospital #2. The DON stated Hospital #2 reported Patient #1 had a fracture to his/her neck and was in a hypertensive crisis. According to the DON, at the Nursing Home Hospital #2 was sending Patient #1 to Hospital #3 for further treatment.

Review of Patient #1's Nursing Home Notes on 04/26/16 at 5:35 PM, revealed a nurse heard Patient #1 yelling for help and upon entering Patient #1's room, the nurse found Patient #1 lying on the floor along his/her left side. A large amount of blood was observed under his/her head and arms. Patient #1 denied pain to his/her hips. Patient #1's left knee was observed to be grossly edematous and slightly painful to touch. When Patient #1 was rolled onto his/her back, the patient was observed to have two (2) large deep lacerations to his/her left eye. One (1) laceration was observed 4 x 2.5 centimeters (cm) located near the eye brow region. The other laceration was observed 3 x 2 cm to the bottom of Patient #1's eye lid. Both lacerations were cleaned and bandaged. Patient #1 was documented to be Alert and oriented to person, place, time and situation. Patient #1 informed the Nursing Home that he/she sat up on the side of bed and fell forward. Further Review of Patient #1's Nursing Notes, on 04/26/16 at 5:55 PM, revealed Emergency Medical Services (EMS) had arrived and Patient #1 had a blood pressure of 132/80 with a pulse of 82.

Review of the EMS Prehospital Care Report, revealed Patient #1 had been picked up on 04/26/16 at 5:47 PM, with a medical history of Hypertension and Renal Failure. Patient #1's primary complaint was a fall with an eye injury. Patient #1's blood pressure was documented at 126/62 with a pulse of 88. The EMS report stated Patient #1's neck was normal.

Review of the Emergency Department's Triage Report at Hospital #1, revealed Patient #1 arrived to the Emergency Room on 04/26/16 at 6:17 PM, with a blood pressure of 188/113. Patient #1 had a chief complaint of head and face injury from a fall which occurred at the Nursing Home. The severity of the fall was documented as moderate with no associated symptoms. Patient #1 had painless range of motion to the neck and it was identified to be non-tender.

Review of Hospital #1's Consultation Report, dated 04/26/16, revealed Patient #1 was admitted through the Emergency Room after a fall from his/her bed in which Patient #1 sustained facial injury. Patient #1 had a medical history of Hypertension. Patient #1 had problems with vision and early signs of Dementia. Patient #1 presented with a complex laceration of the left side of the forehead area above the left eyebrow which goes down to the deep subcutaneous tissue and muscle which was identified to be a laceration. There was no eye injury identified. Further review of the Consultant Report, revealed a CT scan was completed with no facial, nasal or orbital fractures. The left eye was addressed with a thorough irrigation and sutures. Patient #1's eye was then dressed with bacitracin ointment and an occlusive dressing over the eye and the forehead using a 4 x 4 gauze and a kerlix wrap. Patient #1 was given antibiotics and one (1) gram of Rocephin while in the Emergency Room. The Consultation Report revealed a plan to see the patient in forty-eight (48) hours for suture removal.

Review of the Emergency Department's Disposition from Hospital #1, on 04/26/16 at 9:22 PM, revealed Patient #1 was going back to the Nursing Home with a condition that had improved and was stable.

Interview with Registered Nurse (RN) #6 at Hospital #1, on 05/19/16 at 8:00 AM, revealed when she came onto her shift on 04/26/16 at 6:45 PM, she remembered Patient #1 lying in bed and appeared to be comfortable with no complaints of neck pain. RN #6 stated she did not remember who the physician was the night Patient #1 came in; and when Patient #1 was discharged, she felt everything was ok. RN #6 could not remember Patient #1's vitals that night.

Interview with Emergency Department (ED) Doctor #3, on 05/18/16 at 1:26 PM, revealed when Patient #1 was seen in the Emergency Room, he ordered a CT Scan of the head. ED Doctor #3 stated since Patient #1 fell out of the bed, it was considered a minor fall which meant the patient's work up would be different from a patient who had fallen when standing up. Patient #1 had no loss of consciousness and no nausea. ED Doctor #3 stated he remembered looking a Patient #1's injuries. Doctor #3 stated blood pressure elevation in the emergency room was normal. ED Doctor #3 stated if a blood pressure was elevated, the question would be would he treat the blood pressure or not? Patient #1 had no symptoms with the increased blood pressure and no complaints of neck pain. ED Doctor #3 stated a Plastic Surgeon had come into the Emergency Room to repair the injuries to Patient #1's eye and the procedure took one (1) in a half (1/2) hours. ED Doctor #3 stated if a patient had spinal shock, the blood pressure would actually be low. Doctor #3 stated if a patient's neck was broken, the broken neck would not affect the blood pressure. ED Doctor #3 stated pain would cause a patient's blood pressure to go up.

Review of the EMS Prehospital Care Report, dated 04/27/16, revealed Patient #1 was transported back to the Nursing Home at 12:42 AM. Patient #1 had wounds dressed to left eye, left elbow and forearm. Per report Patient #1 had sutures to the Left upper and lower eye. Patient #1 was observed to be hypertensive upon arrival, and the nurse was questioned by EMS and was told Patient #1 had been running a high blood pressure since arrival and that Patient #1 was due for dialysis tomorrow. Patient #1 denied any visual disturbance or headache. Patient #1 was moved to cot via sheet drag by EMS without incident. Once Patient #1 was in the ambulance, Patient #1's vitals were taken and monitored en route to the Nursing Home which was documented to be 201/139 and Pulse 103. EMS was advised that Patient #1 had not had his dialysis yet.

Review of Patient #1's Nursing Notes at the Nursing Home, on 04/27/16 at 1:30 AM, revealed Patient #1 returned to the Nursing Home on 04/27/16 at 12:55 AM. Patient #1 was alert and able to make needs known. Patient #1 was observed to have his/her head and left arm wrapped with gauze. The Emergency Room nurse reported Patient #1's left eye was stitched shut with sutures to brow of eye. A physician was to be called in the morning for follow up with Patient #1's eye. Patient #1's blood pressure was documented to be 199/98. The nurse documented the blood pressure was lower than what the Emergency Room reported. Patient #1 complained of nausea with a small amount of emesis (vomit). Patient #1 stated the ride in the ambulance made him/her sick. Neurological checks were initiated. Patient #1 complained of pain and discomfort to face and arm. Percocet was administered. The nurse documented he would monitor for increased nausea and Hypertension. Patient #1 was due for dialysis in the morning.

Review of Patient #1's Nursing Notes at the Nursing Home, on 04/27/16 at 4:13 AM, revealed at 3:15 AM, during a neurological check, Patient #1 was found difficult to arouse, with a slight droop of the tongue on right side of Patient #1's face with some twitching movements. Patient #1's medical doctor was notified of the continued increase of Patient #1's blood pressure and level of consciousness. An order was obtained to send Patient #1 back to the Emergency Room. The nurse documented once she was back in Patient #1's room, she observed the patient to be sitting up on the side of the bed with the dressing removed from his/her face. Patient #1 was grasping for something. Patient #1 was asked questions and responded in another language. Patient #1's left eye was observed to be red with blood dripping down his/her cheek. The nurse gently cleaned the eye and rewrapped the area. Patient #1's blood pressure was documented as 204/100 and pulse 100.

Review of the EMS Prehospital Care Report, dated 04/27/16, revealed Patient #1 had been picked up at 4:03 AM with a primary complaint of hypertension and altered mental status. Patient #1 had been previously brought back from the Emergency Room with injuries sustained from a fall. Patient #1 had a bandage over the left eye covering the sutures. Patient #1 had been picking at bandage and possibly pulled a suture loose. Patient #1's blood pressure was elevated at 188/134 and pulse 78. According to the report, there were no complaints of headaches, chest pain or nausea and vomiting and no facial droop or slurred speech was observed. Patient #1 didn't appear in distress. Once EMS got to Hospital #1, Patient #1's status was unchanged.

Review of Patient #1's Emergency Department Triage Report (Hospital #1), dated 04/27/16 at 4:33 AM, revealed Patient #1's chief complaint was high blood pressure. Patient #1 had a history of hypertension and was noted to have elevated blood pressure throughout an earlier stay at Hospital #1. The Paramedics reported that Patient #1 had obtained his/her blood pressure medication late due to his/her earlier emergency visit. However, the Nursing Home called EMS that morning due to a report that Patient #1 had vomited once upon return and was acting more confused than normal. The Nursing Home noted that Patient #1's blood pressure was in the 190's systolic. No vomiting had occured during transfer to Emergency Room. The Physical Exam revealed no acute distress, and the neck and thyroid were observed to be normal upon inspection. According to the report Patient #1's chest was non-tender with no respiratory distress with normal breath sounds. Patient #1's heart rate was regular and rhythmic with no heart murmur. Patient #1's abdomen was was observed to be non-tender, no large organs, no distention with normal bowel sounds. There was a normal inspection of the back and Patient #1's Central Nervous system was observed to be normal. A repeat CT scan was performed of the head. When compared to the previous CT scan on 04/26/16 at 9:47 PM, the scan revealed bony structures remained intact, and the sinuses were clear. There continued to be soft tissue swelling over the left periorbital, nasal and maxillary regions. The brain continued to demonstrate generalized atrophy. There was mild periventricular white matter change. There continued to be no acute intracranial process. Complete Blood Count (CBC) was performed as well and reviewed.

Review of Patient #1's Vitals at Hospital #1, revealed on 04/27/16 at 4:35 AM, Patients #1's blood pressure was 180/127, at 5:03 AM Patient #1's blood pressure was 193/103, at 6:03 AM Patient #1's blood pressure was 202/99.

Review of the Medication Administration History Report at Hospital #1, dated 04/27/16 on 06:18 AM, revealed RN #5 administered Clonidine 0.2 mg.

Review of Patient #1's Vitals at Hospital #1, revealed on 04/27/16 at 7:29 AM, Patient #1's blood pressure was documented at 192/98.

Review of the Emergency Department's Disposition at Hospital #1, on 04/27/16 at 6:05 AM, revealed to send Patient #1 back to the nursing home as Patient #1 was stable.

Interview with ED Doctor #1, on 05/18/16 at 1:51 PM, revealed he remembered treating Patient #1 on his/her return visit to the Emergency Department at Hospital #1. ED Doctor #1 stated he remembered Patient #1 had sustained a fall earlier with a facial repair. The ED Doctor #1 remembered the Nursing Home reporting Patient #1 was not acting normal, had some medication issues, vomiting and agitation and reporting Patient #1's blood pressure was elevated. The ED Doctor #1 reviewed Patient #1's previous visit to the Emergency Room and noted Patient #1 had fallen out of bed and hit his/her face on bedside table. Patient #1 was observed to not be mobile. The ED Doctor #1 stated he identified Patient #1's blood pressure was elevated on the first visit and that the Hypertension was chronic. The ED Doctor #1 stated his concern was that Patient #1 was having delayed bleeding. The ED Doctor #1 repeated the CT scan to Patient #1's head. The ED Doctor stated he evaluated Patient #1 and moved all of his/her extremities with no concerns. A fractured neck was not on the top of his list for diagnosis at the time. The ED Doctor #1 was concerned about bleeding of the brain and a closed head injury. The ED Doctor #1 stated he remembered when Patient #1 was due to go back to the Nursing Home. The Nursing Home was upset that Patient #1's blood pressure was high. The ED Doctor #1 stated Patient #1's blood pressure was down upon discharge from Hospital #1. The ED Doctor #1 stated the symptoms for a neck fracture were pain in the neck, paralysis, tingling of fingers and neurological concerns. The ED Doctor #1 stated when the Emergency Room Nurse went to give report to the Nursing Home; the nursing home nurse voiced the facility had declined to receive Patient #1 due to his/her blood pressure being too high. The ED Doctor #1 stated he talked to the nurse at the Nursing Home and informed the nurse not to abandon Patient #1 because ED Doctor #1 felt the facility was trying to abandon the patient. He stated Patient #1's blood pressure was not an issue and there was no Hypertensive Emergency. Patient #1 was asymptomatic with his/her elevated blood pressure. ED Doctor #1 stated he reported to the nurse that he would be happy to talk to Patient #1's doctor. ED Doctor stated Patient #1 had a reason to have elevated blood pressure as Patient #1 was in pain from the facial injuries. ED Doctor #1 stated the patient's Hypertension could be treated at the nursing home. The Nursing Home was not actively treating Patient #1's blood pressure.

Review of EMS Prehospital Care Report, on 04/27/16 at 7:40 AM, revealed Patient #1 was being discharged from Hospital #1. Upon arrival to the Hospital Patient #1 was lying in bed, alert and oriented. Patient #1's blood pressure was observed to be elevated, 160/119. Hospital #1 reported Patient #1 was stable for transport.

Review of Patient #1's Nurses Notes at the Nursing Home, dated 04/27/16 at 8:55 AM, revealed Hospital #1's Emergency Room called the Nursing Home to give report. In report, Hospital #1 informed the Nursing Home that Patient #1 had Clonidine 0.2 mg in the Emergency Room and that his/her blood pressure was 202/98. The nurse explained that Patient #1 did not have high blood pressure and that Patient #1 had a recent trip to the Emergency Room for a head injury. The Emergency Room reported they were going to send Patient #1 back. The Medical Director and Director of Nursing were called and the Nursing Home received new orders to send Patient #1 to Hospital #2 upon return to the Nursing Home from Hospital #1. The EMS returned Patient #1 at 8:15 AM with a blood pressure of 190/100 and 911 was then called for another EMS to take Patient #1 to Hospital #2.

Interview with the Medical Director for the Nursing Home, on 05/24/16 at 1:04 PM, revealed he remembered the Nursing Home Nurse being alarmed about Patient #1's blood pressure. When the Emergency Room Nurse informed the Nursing Home that she was sending Patient #1 back, the Nursing Home called the Medical Director about the blood pressure. The Medical Director stated he then called Hospital #1 and talked to Emergency Department Doctor #2. The Medical Director stated he told ED Doctor #2 his concern and that sending Patient #1 back with a blood pressure of 200/100 was something the Nursing Home could not handle. If Patient #1's blood pressure could come down and be stable for a couple of hours, then the Nursing Home would take Patient #1 back. When the Medical Director got off the phone with the Emergency Department Doctor #2, he then called the Nursing Home and found out Patient #1 was discharged and was being sent back and would arrive in ten (10) minutes.

Interview with the Emergency Department (ED) Doctor #2, on 05/24/16 at 1:30 PM, revealed he did remember talking to the Medical Director at the Nursing Home, but did not remember any conversation with keeping Patient #1 in the Emergency Room for a couple of hours until blood pressure came down. Doctor #2 stated he remembered talking about the Emergency Room Guidelines. Doctor #2 stated the Medical Director kept on stating a Hypertensive Emergency. ED Doctor #2 stated a Hypertensive Emergency was a blood pressure of 220/115 with symptoms. After the conversation with the Medical Director, the Medical Director seemed fine, but about twenty (20) minutes later a nurse (not sure which nurse) reported to Doctor #2 that the Medical Director of the Nursing Home had called back and was very rude. The ED Doctor #2 stated he instructed the nurse that the next time a physician called to complain, have them talk to a medical doctor. The ED Doctor #2 stated if Patient #1 had come into the Emergency Department with a chief complaint of Hypertension, he would have requested a manual blood pressure. He would look at heart rate, vitals and identify if the patient received his/her blood pressure medications. According to ED Doctor #2 if a patient sustained a fracture to the C5 spinal area, this would not cause a patient to have increased blood pressure.

Further interview with the Medical Director at the Nursing Home, on 05/24/16 at 1:04 PM, revealed he was frustrated with Hospital #1 because he thought the Hospital had agreed to keep Patient #1, but then Hospital #1 sent Patient #1 back. The Medical Director stated he called the DON to make her aware he was concerned about the blood pressure of 200/100 and the head injury Patient #1 had sustained. He stated Patient #1 was not appropriate for admission to the Nursing Home. The Medical Director stated the next call he received was from the Paramedics. The Paramedics were questioning to unload Patient #1 at the Nursing Home. The Paramedics stated Patient #1's blood pressure was 200/100. The Medical Director stated he informed the Paramedic that Patient #1 was not stable. The Medical Director stated from his understanding, there was a transfer from one ambulance to another ambulance to take Patient #1 to Hospital #2.


Review of EMS Prehospital Care Report, on 04/27/16 at 7:40 AM, revealed once EMS arrived to the Nursing Home, the staff at the Nursing Home met the EMS crew and advised them that due to Patient #1's blood pressure, the Nursing Home could not receive Patient #1 per their Medical Director. The Nursing Home refused to let Patient #1 in the building. The Nursing Home called 911 to have Patient #1 transported to Hospital #2.

Review of EMS Prehospital Care Report, on 04/27/16 at 8:35 AM, revealed EMS arrived to the Nursing Home to transfer Patient #1 from one EMS crew to the other EMS crew. The EMS crew was advised the Nursing Home staff refused to accept Patient #1 after being discharged from Hospital #1. Patient #1 had no complaints of pain. Patient #1 was disoriented to time and place and was not sure if this was normal for Patient #1 before or after the fall. Patient #1's blood pressure was 170/116.

Interview with Paramedic, on 05/24/16 at 12:35 PM, revealed he came to the Nursing Home about 8:00 AM on 04/27/16 to pick up Patient #1 and transport him/her to Hospital #2. The Nursing Home would not let Patient #1 in the door of the Nursing Home. Patient #1 was not alert, but his/her vitals were stable. The Paramedic stated the transfer was not considered an emergency. The Paramedic stated he did not remember the patient complaining of any pain. The Paramedic stated he did not talk to the Medical Director or the nursing staff at the Nursing Home.

Interview with Emergency Medical Technician (EMT), on 05/25/16 at 11:05 AM, revealed she remembered being notified that the team needed to go to the Nursing Home to pick up Patient #1. The Nursing Home was refusing to take Patient #1. The EMT stated when she arrived to the nursing home, the first ambulance had the patient in their vehicle and the crew stated the Nursing Home would not take Patient #1 so "we placed Patient #1 in our vehicle." The EMT stated she remembered Patient #1 having a large bump on his/her head and blood pressure was stable. The EMT stated she transferred Patient #1 to Hospital #2. She returned to Hospital #2, and found out Hospital #2 flew Patient #1 to Hospital #3.

Review of Hospital #2's Emergency Documentation for Patient #1, completed by ED Doctor #9, on 04/27/16 at 9:40 AM, revealed Patient #1 had a history of significant end stage renal disease with dialysis days of Monday, Wednesday and Friday with Hypertension, who presented to the Emergency Room after two (2) falls. Patient #1 reported he/she lived in a Nursing Home but could not recall why he/she fell or the events surrounding the fall. Patient #1 was found to have a laceration on the left brow and left lower eyelid and skin tears to the left upper extremity. Patient #1 was seen twice (2) by Hospital #1 and discharged back to the Nursing home. When Patient #1 was discharged to the Nursing Home the morning of 04/27/16, the Nursing Home found Patient #1 to be quite Hypertensive and sent Patient #1 to Hospital #2. The Nursing Home refused to accept Patient #1 back. Patient #1 complained of pain to his/her left brow, left side of his/her face and left forearm. Patient #1 has denied any other injuries. Patient #1 was only alert to person. Further review of the Emergency Documentation revealed ED Doctor #9 assessed Patient #1's neck was supple, trachea midline. However, Patient #1 had tenderness in the posterior aspect of the neck. Pupils were equal, round and reactive to light, normal range of motion, normal strength, no tenderness, swelling or deformity to Patient #1's musculoskeletal system. Patient #1's blood pressure was 167/106 with a pulse rate of 76. Further review of Patient #1's tests, revealed Patient #1's cardiac monitor was normal sinus rhythm, chest x-ray revealed no acute disease process. The CT scan of the head, revealed no acute disease process, and no intracranial hemorrhage. The CT of the cervical spine showed a non-displaced C4 spinous process fracture and a possible fracture of the transverse process of C5. Patient #1 was then transferred to Hospital #3 on 04/27/16 at 11:14 AM with a diagnosis of Spinous Process Fracture, Transverse Process Fracture, Laceration to Eye Brow, Laceration to Left Inferior Eyelid, Vision Loss of Left Eye, Skin Tears and Hypertensive Urgency.

Interview with RN #8 at Hospital #2, on 05/25/16 at 9:41 AM, revealed Patient #1 came into the ER with Hypertension. The EMS had informed her they tried to take Patient #1 to the Nursing Home, but they refused. Patient #1 had complained about neck pain. RN #8 stated she did not move the patient. She placed a C-Colar (a bandage that secures the neck) on Patient #1 when he/she complained of pain. RN #1 stated she did not receive report of a spinal fracture, but Hospital #2 identified Patient #1 had a spinal fracture. RN #8 stated she did not administer any blood pressure medication to Patient #1.

Interview with ED Doctor #9, on 05/25/16 at 9:34 AM, revealed he remembered Patient #1 was seen twice (2) by Hospital #1 and the Nursing Home was concerned about Patient #1 not receiving a good exam. Patient #1 was observed to be pleasant with a laceration to his/her eye, and skin tears on arms and legs. A CT scan of spine and neck revealed a fracture to Patient #1's neck. It was a C4 spine transverse fracture which was treated non-surgically. According to ED Dr. #9, Patient #1's blood pressure was 167/106.

Review of Hospital #3's History and Physical for Patient #1, on 04/28/16, revealed Patient #1 was admitted with a Hypertensive Urgency and Altered Mental Status. Two (2) days prior, Patient #1 had fallen and had left eyelid laceration repaired at Hospital #1. Chest X-ray revealed a left lower lung infiltrate concerning for pneumonia verses pulmonary contusion. The Hypertensive Urgency eventually responded to IV blood pressure medications, dialysis and pain control. Patient #1's altered mental status was likely secondary to pain and pneumonia. A CT of neck showed an acute nondisplaced C4 vertebral fracture. Patient #1 was evaluated by Hospital #3's Ortho spine specialists and the recommendation was a C Collar until follow up, which was scheduled for 06/17/16. Patient #1 was discharged from Hospital #3 on 05/03/16 back to Nursing Home.

Review of the Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department with Asymptomatic Elevated Blood Pressure (Hospital #1), July 2013, revealed in patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention was not required.

Based on review of Patient #1's medical record, policies and interviews, it was determined the facility failed to provide stabilizing treatment as related to their failure to evaluate for hypertension and fractures to the cervical spine for one patient (#1) in the selected sample of twenty (20).

Findings include:

Review of Hospital #1's Consultation Report, dated 04/26/16, revealed Patient #1 was admitted through the Emergency Room after a fall from his/her bed in which Patient #1 sustained a facial injury. Patient #1 had a past medical history of Hypertension. Patient #1 had problems with vision and early signs of Dementia. Patient #1 presented with a complex laceration of the left side of the forehead area above the left eyebrow which goes down to the deep subcutaneous tissue and muscle which was identified to be a laceration. There was no eye injury identified. Further review of the Consultant Report, revealed a CT scan was completed with no facial, nasal or orbital fractures. The left eye was addressed with a thorough irrigation and sutures. Patient #1's eye was then dressed with bacitracin ointment and an occlusive dressing over the eye and the forehead using a 4 x 4 gauze and a kerlix wrap. Patient #1 was given antibiotics and one (1) gram of Rocephin while in the Emergency Room. The Consultation Report revealed a plan to see the patient in forty-eight (48) hours for suture removal.

Review of the Emergency Department's Disposition from Hospital #1, on 04/26/16 at 9:22 PM, revealed Patient #1 was going back to the Nursing Home.

Interview with Emergency Department (ED) Doctor #3, on 05/18/16 at 1:26 PM, revealed when Patient #1 was seen in the Emergency Room, he ordered a CT Scan of the head. ED Doctor #3 stated since Patient #1 fell out of the bed, it was considered a minor fall which meant the patients work up would be different from a patient who had fallen when standing up. Patient #1 had no loss of consciousness and no nausea. ED Doctor #3 stated he remembered looking a Patient #1's injuries. Doctor #3 stated blood pressure elevation in the emergency room was normal. ED Doctor #3 stated if a blood pressure was elevated, the question would be would he treat the blood pressure or not? Patient #1 had no symptoms with the increased blood pressure and no complaints of neck pain. ED Doctor #3 stated a Plastic Surgeon had come into the Emergency Room to repair the injuries to Patient #1's eye and the procedure took one (1) in a half (1/2) hours. ED Doctor #3 stated if a patient had spinal shock, the blood pressure would actually be low. Doctor #3 stated if a patient's neck was broken, the broken neck would not affect the blood pressure. ED Doctor #3 stated pain would cause a patient's blood pressure to go up.

Review of Patient #1's Nursing Notes at the Nursing Home, on 04/27/16 at 4:13 AM, revealed at 3:15 AM, during a neurological check, Patient #1 was found difficult to arouse, with a slight droop of the tongue on right side of Patient #1's face with some twitching movements. Patient #1's medical doctor was notified of the continued increase of Patient #1's blood pressure and level of consciousness. An order was obtained to send Patient #1 back to the Emergency Room. The nurse documented once she was back in Patient #1's room, she observed the patient to be sitting up on the side of the bed with the dressing removed from his/her face. Patient #1 was grasping for something. Patient #1 was asked questions and responded in another language. Patient #1's left eye was observed to be red with blood dripping down his/her cheek. The nurse gently cleaned the eye and rewrapped the area. Patient #1's blood pressure was documented as 204/100 and pulse 100.

Review of the EMS Prehospital Care Report, dated 04/27/16, revealed Patient #1 had been picked up at 4:03 AM with a primary complaint of hypertension and altered mental status. Patient #1 had been previously brought back from the Emergency Room with injuries sustained from a fall. Patient #1 had a bandage over the left eye covering sutures. Patient #1 had been picking at the bandage and possibly pulled a suture loose. Patient #1's blood pressure was elevated at 188/134 and pulse 78. According to the report there were no complaints of headaches, chest pain or nausea and vomiting and no facial droop or slurred speech was observed. Patient #1 did not appear in distress. Once EMS arrived to Hospital #1, Patient #1's status was unchanged.

Review of Patient #1's Emergency Department Triage Report (Hospital #1), dated 04/27/16 at 4:33 AM, revealed Patient #1's chief complaint was high blood pressure. Patient #1 had a history of hypertension and was noted to have elevated blood pressure throughout an earlier stay at Hospital #1. The Paramedics reported that Patient #1 had obtained his/her blood pressure medication late due to his/her earlier emergency visit. However, the Nursing Home called EMS that morning due to a report that Patient #1 had vomited once upon return and was acting more confused than normal. The Nursing Home noted that Patient #1's blood pressure was in the 190's systolic. No vomiting had occurred during transfer to Emergency Room. The Physical Exam, revealed no acute distress,and the neck and thryoid were observed to be normal upon inspection. Accoroding to the report Patient #1's chest was non-tender with no respiratory distress with normal breath sounds. Patient #1's heart rate was regular and rhythmic with no heart murmur. Patient #1's abdomen was observed to be non-tender, no large organs, no distention with normal bowel sounds. There was a normal inspection of the back. Patient #1's Central Nervous system was observed to be normal. A repeat CT scan was performed of the head. When compared to the previous CT scan on 04/26/16 at 9:47 PM, the scan revealed bony structures remained intact, and the sinuses were clear. There continued to be soft tissue swelling over the left periorbital, nasal and maxillary regions. The brain continued to demonstrate generalized atrophy. There was mild periventricular white matter change. There continued to be no acute intracranial process. Complete Blood Count (CBC) was performed as well and reviewed.

Review of Patient #1's Vitals at Hospital #1, revealed on 04/27/16 at 4:35 AM, Patients #1's blood pressure was 180/127, at 5:03 AM Patient #1's blood pressure was 193/103, at 6:03 AM Patient #1's blood pressure was 202/99.

Interview with ED Doctor #1, on 05/18/16 at 1:51 PM, revealed he remembered treating Patient #1 on his/her return visit to the Emergency Department at Hospital #1. ED Doctor #1 stated he remembered Patient #1 had sustained a fall earlier with a facial repair. ED Doctor #1 remembered the Nursing Home reporting Patient #1 was not acting normal, had some medication issues, vomiting and agitation and reporting Patient #1's blood pressure was elevated. ED Doctor #1 reviewed Patient #1's previous visit to the Emergency Room and noted Patient #1 had fallen out of bed and hit his/her face on bedside table. Patient #1 was observed to not be mobile. ED Doctor #1 stated he identified Patient #1's blood pressure was elevated on the first visit and that the Hypertension was chronic. ED Doctor #1 stated his concern was that Patient #1 was having delayed bleeding. ED Doctor #1 repeated the CT scan to Patient #1's head. The ED Doctor stated he evaluated Patient #1 and moved all of his/her extremities with no concerns. A fractured neck was not on the top of his list for diagnosis at the time. According to ED Doctor #1 he was concerned about bleeding of the brain and a closed head injury. The ED Doctor #1 stated he remembered when Patient #1 was due to go back to the Nursing Home. The Nursing Home was upset that Patient #1's blood pressure was high. ED Doctor #1 stated Patient #1's blood pressure was down upon discharge from Hospital #1. The ED Doctor #1 stated the symptoms for a neck fracture were pain in the neck, paralysis, tingling of fingers and neurological concerns. ED Doctor #1 stated when the Emergency Room Nurse went to give report to the Nursing Home; the nursing home nurse voiced the facility had declined to receive Patient #1 due to his/her blood pressure being too high. The ED Doctor #1 stated he talked to the nurse at the Nursing Home and informed the nurse not to abandon Patient #1 because ED Doctor #1 felt the facility was trying to abandon the patient. He stated Patient #1's blood pressure was not an issue and there was no Hypertensive Emergency. Patient #1 was asymptomatic with his/her elevated blood pressure. ED Doctor #1 stated he reported to the nurse that he would be happy to talk to Patient #1's doctor. The ED Doctor stated Patient #1 had a reason to have elevated blood pressure as Patient #1 was in pain from the facial injuries. ED Doctor #1 stated the patient's Hypertension could be treated at the nursing home. The Nursing Home was not actively treating Patient #1's blood pressure.

Review of Patient #1's Nurses Notes at the Nursing Home, dated 04/27/16 at 8:55 AM, revealed Hospital #1's Emergency Room called the Nursing Home to give report. In report, Hospital #1 informed the Nursing Home that Patient #1 had Clonidine 0.2 mg in the Emergency Room and that his/her blood pressure was 202/98. The nurse explained that Patient #1 did not have high blood pressure and that Patient #1 had a recent trip to the Emergency Room for a head injury. The Emergency Room reported they were going to send Patient #1 back to the Nursing Home. The Medical Director and Director of Nursing were called and the Nursing Home received new orders to send Patient #1 to Hospital #2 upon return to the Nursing Home from Hospital #1. The EMS returned Patient #1 at 8:15 AM with a blood pressure of 190/100 and 911 was then called for another EMS to take Patient #1 to Hospital #2.

Interview with the Emergency Department (ED) Doctor #2, on 05/24/16 at 1:30 PM, revealed he did remember talking to the Medical Director at the Nursing Home, but did not remember any conversation with keeping Patient #1 in the Emergency Room for a couple of hours until blood pressure came down. Doctor #2 stated he remembered talking about the Emergency Room Guidelines. Doctor #2 stated the Medical Director kept on stating a Hypertensive Emergency. ED Doctor #2 stated a Hypertensive Emergency was a blood pressure of 220/115 with symptoms. After the conversation with the Medical Director, the Medical Director seemed fine, but about twenty (20) minutes later a nurse (not sure which nurse) reported to Doctor #2 that the Medical Director of the Nursing Home had called back and was very rude. The ED Doctor #2 stated he instructed the nurse that the next time a physician called to complain, have them talk to a medical doctor. The ED Doctor #2 stated if Patient #1 had come into the Emergency Department with a chief complaint of Hypertension, he would have requested a manual blood pressure. He would look at heart rate, vitals and identify if the patient received his/her blood pressure medications. According to ED #2 if a patient sustained a fracture to the C5 spinal area, this would not cause a patient to have increased blood pressure.

Interview with the Medical Director for the Nursing Home, on 05/24/16 at 1:04 PM revealed he remembered the Nursing Home Nurse being alarmed about Patient #1's blood pressure. When the Emergency Room Nurse informed the Nursing Home that she was sending Patient #1 back, the Nursing Home called the Medical Director about the blood pressure. The Medical Director stated he then called the Hospital #1 and talked to Emergency Department Doctor #2. The Medical Director stated he told ED Doctor #2 his concern and that sending Patient #1 back with a blood pressure of 200/100 was something the Nursing Home could not handle. If Patient #1's blood pressure could come down and be stable for a couple of hours, then the Nursing Home would take Patient #1 back. When the Medical Director got off the phone with the Emergency Department Doctor #2, he then called the Nursing Home and found out Patient #1 was discharged and was being sent back and would arrive in ten (10) minutes. Further interview with the Medical Director at the Nursing Home revealed he was frustrated with Hospital #1 because he thought the Hospital had agreed to keep Patient #1, but then Hospital #1 sent Patient #1 back. The Medical Director stated he called the DON to make her aware he was concerned about the blood pressure of 200/100 and the head injury Patient #1 had sustained. He stated Patient #1 was not appropriate for admission to the Nursing Home. The Medical Director stated the next call he received was from the Paramedics. The Paramedics were questioning to unload Patient #1 at the Nursing Home. The Paramedics stated Patient #1's blood pressure was 200/100. The Medical Director from the Nursing Home stated he informed the Paramedic that Patient #1 was not stable. The Medical Director stated from his understanding, there was a transfer from one ambulance to another ambulance to take Patient #1 to Hospital #2.

Review of EMS Prehospital Care Report, on 04/27/16 at 7:40 AM, revealed once EMS arrived to the Nursing Home, the staff at the Nursing Home met the EMS crew and advised them that due to Patient #1's blood pressure, the Nursing Home could not receive Patient #1 per their Medical Director. The Nursing Home refused to let Patient #1 in the building. The Nursing Home called 911 to have Patient #1 transported to Hospital #2.

Interview with Emergency Medical Technician (EMT), on 05/25/16 at 11:05 AM, revealed she remembered being notified that the team needed to go to the Nursing Home to pick up Patient #1. The Nursing Home was refusing to take Patient #1. The EMT stated when she arrived at the nursing home, the first ambulance had the patient in their vehicle and the crew stated the Nursing Home would not take Patient #1 so "we placed Patient #1 in our vehicle." The EMT stated she remembered Patient #1 having a large bump on his/her head and blood pressure was stable. The EMT stated she transferred Patient #1 to Hospital #2. She returned to Hospital #2 and found out Hospital #2 flew Patient #1 to Hospital #3.

Review of Hospital #2's Emergency Documentation for Patient #1, completed by ED Doctor #9, on 04/27/16 at 9:40 AM, revealed Patient #1 had a history of significant end stage renal disease with dialysis days of Monday, Wednesday and Friday with Hypertension, who presented to the Emergency Room after two (2) falls. Patient #1 reported he/she lived in a Nursing Home but could not recall why he/she fell or the events surrounding the fall. Patient #1 was found to have a laceration on the left brow and left lower eyelid and skin tears to the left upper extremity. Patient #1 was seen twice (2) by Hospital #1 and discharged home. When Patient #1 was discharged to the Nursing Home the morning of 04/27/16, the Nursing Home found Patient #1 to be quite Hypertensive and sent Patient #1 to Hospital #2. The Nursing Home refused to accept Patient #1 back. Patient #1 complained of pain to his/her left brow, left side of his/her face and left forearm. Patient #1 has denied any other injuries. Patient #1 was only alert to person. Further review of the Emergency Documentation revealed ED Doctor #9 assessed Patient #1's neck was supple, trachea midline. However, Patient #1 had tenderness in the posterior aspect of the neck. Pupils were equal, round and reactive to light, normal range of motion, normal strength, no tenderness, swelling or deformity to Patient #1's musculoskeletal system. Patient #1's blood pressure was 167/106 with a pulse rate of 76. Further review of Patient #1's tests revealed Patient #1's cardiac monitor was normal sinus rhythm, and chest x-ray revealed no acute disease process. The CT scan of the head, revealed no acute disease process, and no intracranial hemorrhage. The CT of the cervical spine showed a non-displaced C4 spinous process fracture and a possible fracture of the transverse process of C5. Patient #1 was transferred to Hospital #3 on 04/27/16 at 11:14 AM with a diagnosis of Spinous Process Fracture, Transverse Process Fracture, Laceration to Eye Brow, Laceration to Left Inferior Eyelid, Vision Loss of left Eye, Skin Tears and Hypertensive Urgency.

Interview with RN #8 at Hospital #2, on 05/25/16 at 9:41 AM, revealed Patient #1 came into the ER with Hypertension. The EMS had informed her they tried to take Patient #1 to the Nursing Home, but they refused. Patient #1 had complained about neck pain. RN #8 stated she did not move the patient. She placed a C-Colar (a bandage that secures the neck) on Patient #1 when he/she complained of pain. RN #1 stated she did not receive report of a spinal fracture, but Hospital #2 identified Patient #1 had a spinal fracture. RN #8 stated she did not administer any blood pressure medication to Patient #1.

Interview with ED Doctor #9, on 05/25/16 at 9:34 AM, revealed he remembered Patient #1 was seen twice (2) by Hospital #1 and the Nursing Home was concerned about Patient #1 not receiving a good exam. Patient #1 was observed to be pleasant with a laceration to his/her eye, and skin tears on arms and legs. A CT scan of spine and neck revealed a fracture to Patient #1's neck. It was a C4 spine transverse fracture which was treated non-surgically. According to ED Dr. #9, Patient #1's blood pressure was 167/106.

Review of Hospital #3's History and Physical for Patient #1, on 04/28/16, revealed Patient #1 was admitted with a Hypertensive Urgency and Altered Mental Status. Two (2) days prior, Patient #1 had fallen and had a left eyelid laceration repaired at Hospital #1. A Chest X-ray revealed a left lower lung infiltrate concerning for pneumonia verses pulmonary contusion. The Hypertensive Urgency eventually responded to IV blood pressure medications, dialysis and pain control. Patient #1's altered mental status was likely secondary to pain and pneumonia. A CT scan of the neck showed an acute nondisplaced C4 vertebral fracture. Ortho Spine Specialists evaluated Patient #1 and recommended a C Collar until follow up, which was scheduled for 06/17/16. Patient #1 was discharged from Hospital #3 on 05/03/16 back to Nursing Home.

Based on review of Patient #1's medical record and interviews, it was determined the facility failed to provide an appropriate medical screening exam and stabilizing treatment causing a delay in treatment for one patient (#1) in the selected sample of twenty (20).

Findings include:

Review of Patient #1's Emergency Department Triage Report (Hospital #1), dated 04/27/16 at 4:33 AM, revealed Patient #1's chief complaint was high blood pressure. Patient #1 had a history of hypertension and was noted to have elevated blood pressure throughout an earlier stay at Hospital #1. The Paramedics reported that Patient #1 had obtained his/her blood pressure medication late due to his/her earlier emergency visit. However, the Nursing Home called EMS that morning due to a report that Patient #1 had vomited once upon return and was acting more confused than normal. The Nursing Home noted that Patient #1's blood pressure was in the 190's systolic. No vomiting had occurred during transfer to Emergency Room. The Physical Exam, revealed no acute distress, and the neck anf thyroid were observed to be normal upon inspection. According to the report Patient #1's was chest non-tender with no respiratory distress with normal breath sounds. Patient #1's heart rate was regular and rhythmic with no heart murmur. Patient #1's abdomen was non-tender, no large organs, no distention with normal bowel sounds. There was a normal inspection of the back. Patient #1's Central Nervous system was observed to be normal. A repeat CT scan was performed of the head. When compared to a previous CT scan on 04/26/16 at 9:47 PM, the scan revealed bony structures remained intact, and the sinuses were clear. There continued to be soft tissue swelling over the left periorbital, nasal and maxillary regions. The brain continued to demonstrate generalized atrophy. There was mild periventricular white matter change. There continued to be no acute intracranial process. A Complete Blood Count (CBC) was performed as well and reviewed.

Interview with Emergency Department (ED) Doctor #3, on 05/18/16 at 1:26 PM, revealed when Patient #1 was seen in the Emergency Room, he ordered a CT Scan of the head. ED Doctor #3 stated since Patient #1 fell out of the bed, it was considered a minor fall which meant the patients work up would be different from a patient who had fallen when standing up. Patient #1 had no loss of consciousness and no nausea. ED Doctor #3 stated he remembered looking a Patient #1's injuries. Doctor #3 stated blood pressure elevation in the emergency room was normal. ED Doctor #3 stated if a blood pressure was elevated, the question would be would he treat the blood pressure or not? Patient #1 had no symptoms with the increased blood pressure and no complaints of neck pain. ED Doctor #3 stated a Plastic Surgeon had come into the Emergency Room to repair the injuries to Patient #1's eye and the procedure took one (1) in a half (1/2) hours. ED Doctor #3 stated if a patient had spinal shock, the blood pressure would actually be low. Doctor #3 stated if a patient's neck was broken, the broken neck would not affect the blood pressure. ED Doctor #3 stated pain would cause a patient's blood pressure to go up.

Interview with ED Doctor #1, on 05/18/16 at 1:51 PM, revealed he remembered treating Patient #1 on his/her return visit to the Emergency Department at Hospital #1. ED Doctor #1 stated he remembered Patient #1 had sustained a fall earlier with a facial repair. The ED Doctor #1 remembered the Nursing Home reporting Patient #1 was not acting normal, had some medication issues, vomiting and agitation and reporting Patient #1's blood pressure was elevated. The ED Doctor #1 reviewed Patient #1's previous visit to the Emergency Room and noted Patient #1 had fallen out of bed and hit his/her face on bedside table. Patient #1 was observed to not be mobile. ED Doctor #1 stated he identified Patient #1's blood pressure was elevated on the first visit and that the Hypertension was chronic. ED Doctor #1 stated his concern was that Patient #1 was having delayed bleeding. ED Doctor #1 repeated the CT scan to Patient #1's head. ED Doctor stated he evaluated Patient #1 and he/she moved all of his/her extremities with no concerns at the time. A fractured neck was not on the top of his list for diagnosis according to ED Doctor #1 his concern was related to bleeding of the brain and a closed head injury. The ED Doctor #1 stated he remembered when Patient #1 was due to go back to the Nursing Home as the Nursing Home was upset that Patient #1's blood pressure was high. ED Doctor #1 stated Patient #1's blood pressure was down upon discharge from Hospital #1. The ED Doctor #1 stated the symptoms for a neck fracture were pain in the neck, paralysis, tingling of fingers and neurological concerns. The ED Doctor #1 stated when the Emergency Room Nurse went to give report to the Nursing Home; the nursing home nurse voiced the facility had declined to receive Patient #1 due to his/her blood pressure being too high. The ED Doctor #1 stated he talked to the nurse at the Nursing Home and informed the nurse not to abandon Patient #1 because ED Doctor #1 felt the facility was trying to abandon the patient. He stated Patient #1 blood pressure was not an issue and there was no Hypertensive Emergency. Patient #1 was asymptomatic with his/her elevated blood pressure. The ED Doctor #1 stated he reported to the nurse that he would be happy to talk to Patient #1's doctor. The ED Doctor #1 stated Patient #1 had a reason to have elevated blood pressure as Patient #1 was in pain from the facial injuries and his/her Hypertension could be treated at the nursing home. The Nursing Home was not actively treating Patient #1's blood pressure.

Review of Hospital #2's Emergency Documentation for Patient #1, completed by ED Doctor #9, on 04/27/16 at 9:40 AM, revealed Patient #1 had a history of significant end stage renal disease with dialysis days of Monday, Wednesday and Friday with Hypertension, who presented to the Emergency Room after two (2) falls. Patient #1 reported he/she lived in a Nursing Home but could not recall why he/she fell or the events surrounding the fall. Patient #1 was found to have a laceration on the left brow and left lower eyelid and skin tears to the left upper extremity. Patient #1 was seen twice (2) by Hospital #1 and discharged home. When Patient #1 was discharged to the Nursing Home the morning of 04/27/16, the Nursing Home found Patient #1 to be quite Hypertensive and sent Patient #1 to Hospital #2. The Nursing Home refused to accept Patient #1 back. Patient #1 complained of pain to his/her left brow, left side of his/her face and left forearm. Patient #1 has denied any other injuries. Patient #1 was only alert to person. Further review of the Emergency Documentation revealed ED Doctor #9 assessed Patient #1's neck was supple, trachea midline. However, Patient #1 had tenderness in the posterior aspect of the neck. Pupils were equal, round and reactive to light, normal range of motion, normal strength, no tenderness, swelling or deformity to Patient #1's musculoskeletal system. Patient #1's blood pressure was 167/106 with a pulse rate of 76. Further review of Patient #1's tests, revealed Patient #1's cardiac monitor was normal sinus rhythm, chest x-ray revealed no acute disease process. The CT scan of the head, revealed no acute disease process, and no intracranial hemorrhage. The CT of the cervical spine showed a non-displaced C4 spinous process fracture and a possible fracture of the transverse process of C5. Patient #1 was transferred to Hospital #3 on 04/27/16 at 11:14 AM with a diagnosis of Spinous Process Fracture, Transverse Process Fracture, Laceration to Eye Brow, Laceration to Left Inferior Eyelid, Vision Loss of Left Eye, Skin Tears and Hypertensive Urgency.

Interview with ED Doctor #9, on 05/25/16 at 9:34 AM, revealed he remembered Patient #1 was seen twice (2) by Hospital #1 and the Nursing Home was concerned about Patient #1 not receiving a good exam. Patient #1 was observed to be pleasant with a laceration to his/her eye, and skin tears on arms and legs. A CT scan of spine and neck revealed a fracture to Patient #1's neck. It was a C4 spine transverse fracture which was treated non-surgically. According to ED Dr. #9, Patient #1's blood pressure was 167/106.

Interview with RN #8 at Hospital #2, on 05/25/16 at 9:41 AM, revealed Patient #1 came into the ER with Hypertension. The EMS had informed her they tried to take Patient #1 to the Nursing Home, but they refused. Patient #1 had complained about neck pain. RN #8 stated she did not move the patient. She placed a C-Colar (a bandage that secures the neck) on Patient #1 when he/she complained of pain. RN #1 stated she did not receive report of a spinal fracture, but Hospital #2 identified Patient #1 had a spinal fracture. RN #8 stated she did not administer any blood pressure medication to Patient #1.

Review of Hospital #3's History and Physical for Patient #1, on 04/28/16, revealed Patient #1 was admitted with a Hypertensive Urgency and Altered Mental Status. Two (2) days prior, Patient #1 had fallen and had left eyelid laceration repaired at Hospital #1. A Chest X-ray revealed a left lower lung infiltrate concerning for pneumonia verses pulmonary contusion. The Hypertensive Urgency eventually responded to IV blood pressure medications, dialysis and pain control. Patient #1's altered mental status was likely secondary to pain and pneumonia. A CT scan of the neck showed an acute nondisplaced C4 vertebral fracture. Patient #1 was evaluated by Hospital #3's Ortho spine specialists and the recommendation was a C Collar until follow up, which was scheduled for 06/17/16. Patient #1 was discharged from Hospital #3 on 05/03/16 back to Nursing Home.