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Based on interview and record review, the facility failed to provide necessary stabilizing treatment for an emergent medical condition (EMC- a health condition or situation that needs immediate medical attention. Example: chest pain, stroke [Blood clot in the brain], heavy bleeding, and severe head injury) for one of 21 sampled patients (Patient 1), in accordance with the facility's policy regarding "Emergency Medical Screening Examination Treatment and Transfer," and "Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department." Patient 1 presented to the Emergency Department (ED) with chest pain, shortness of breath (difficulty breathing), headache, left arm and left leg numbness, left shoulder pain, and facial numbness.

This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1's emergent medical condition of acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). This deficient practice had the potential for Patient harm. (Refer to A-2407)

Findings:

During a concurrent interview and record review on 4/3/2025 at 10 a.m. with the Assistant Director of Emergency Department (ADED), Patient 1's Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The Emergency Department Patient Care Timeline indicated Patient 1 arrived in the Emergency Department (ED) at 6:07 p.m., with a chief complaint of "chest pain, shortness of breath, headache, left arm and left leg numbness, left shoulder pain, and facial numbness" and "LKWT (Last known well time) 11 p.m. on 3/2/2025." Patient 1 was triaged (Acuity Level) on 3/3/2025 at 6:07 p.m., as Emergency Severity Index (ESI) level-3 (Urgent- Requires 2 or more resources to provide relief and make a diagnosis). Vital Signs were as follows: Temperature: 97.8F (normal 97F to 99F); Pulse 99 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure169/99 (normal BP 120/80); Pulse oximetry 98% on room air (RA) and with 10/10 Pain assessment.

During a review of Patient 1's Physician Orders dated 3/3/2025 at 6:17 p.m., the Physician's Orders indicated the following: Electrocardiogram (a simple, painless test that records the electrical activity of the heart, helping doctors assess heart health and identify potential problems like irregular heartbeats or heart attacks); complete blood count (a blood test that measures the components of blood, including red blood cells, white blood cells, and platelets); basic metabolic panel (a common blood test that assesses your body's metabolism, fluid balance [the body's ability to maintain a stable internal environment by regulating the amount and distribution of fluids, ensuring proper hydration and electrolyte levels, and supporting vital functions like cellular metabolism and temperature regulation], and kidney function, measuring levels of glucose [sugar], electrolytes [essential minerals vital to many key functions of the body], and kidney waste products); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged; Chest Xray; CT (Computed Tomography, a medical imaging technique that uses X-rays to create detailed, three-dimensional images of internal organs and structures within the body)0 of Head and MRI (Magnetic Resonance Imaging, an imaging technique that uses a strong magnetic field and radio waves to create detailed images of the inside of the body) of Brain. Patient 1 was roomed at 7:54 p.m. and Patient 1's MSE (Medical Screening Exam) was at 7:59 p.m.

During a review of Patient 1's ED physician Notes, dated 3/3/2025, the ED Physician's Notes indicated Patient 1's diagnosis was acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). Patient 1's MRI of the brain ordered on 3/3/2025 indicated findings of "Acute CVA (cerebrovascular accident, a bleed in the brain)."

During a concurrent interview and record review on 4/3/2025 at 10:30 a.m. with the ADED, Patient 1's Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The ADED confirmed there was no documentation of a Registered Nurse (RN) in Triage (a preliminary nursing assessment to determine urgency of need for treatment), nor was there Physician assessment. The ADED confirmed lab (laboratory) and imaging orders for Patient 1. The ADED confirmed there was no documentation of "Stroke Alert (a medical notification that indicates a patient may be experiencing a stroke)," called by Triage RN and no "Code Stroke (a hospital protocol, an emergency alert, initiated when a patient is suspected of having a stroke)," called by the physician.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination Treatment and Transfer," dated 2/16/2024, the P&P indicated "the facility will provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the Emergency Department (ED) to determine if an Emergency Medical Condition (EMC) exists. A MSE will be provided within the capabilities and capacity of the emergency department." "If after the MSE it is determined that the individual has an EMC the hospital must within its capability and capacity to provide further medical examination and treatment required to stabilize the EMC."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department," dated 11/2024, the P&P indicated "overall goal of Stroke Treatment in the Emergency Department are rapid safe and appropriate assessment and treatment of patients exhibiting signs and symptoms concerning for acute stroke" and "Stroke Alert is level 1 activation by nursing after rapid assessment of patient identified to have signs and symptoms potential for stroke with a last known well time of 24 hours prior" and "Code Stroke is level two activation decided by the physician after Stroke Alert and prompt quick medical assessment of the patient."

Based on interview and record review, the facility failed to provide necessary stabilizing treatment for an emergent medical condition (EMC- a health condition or situation that needs immediate medical attention. Example: chest pain, stroke [Blood clot in the brain], heavy bleeding, and severe head injury) for one of 21 sampled patients (Patient 1). Patient 1 presented to the Emergency Department (ED) with chest pain, shortness of breath (difficulty breathing), headache, left arm and left leg numbness, left shoulder pain, and facial numbness.

This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1's emergent medical condition of acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). This deficient practice had the potential for Patient harm.

Findings:

During a concurrent interview and record review on 4/3/2025 at 10 a.m. with the Assistant Director of Emergency Department (ADED), Patient 1's Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The Emergency Department Patient Care Timeline indicated Patient 1 arrived in the Emergency Department (ED) at 6:07 p.m., with a chief complaint of "chest pain, shortness of breath, headache, left arm and left leg numbness, left shoulder pain, and facial numbness" and "LKWT (Last known well time) 11 p.m. on 3/2/2025." Patient 1 was triaged (Acuity Level) on 3/3/2025 at 6:07 p.m., as Emergency Severity Index (ESI) level-3 (Urgent- Requires 2 or more resources to provide relief and make a diagnosis). Vital Signs were as follows: Temperature: 97.8F (normal 97F to 99F); Pulse 99 (normal 60 to 100); Respiration rate (RR): 18 breaths per minute (normal RR 12 to 20); Blood Pressure169/99 (normal BP 120/80); Pulse oximetry 98% on room air (RA) and with 10/10 Pain assessment.

During a review of Patient 1's Physician Orders dated 3/3/2025 at 6:17 p.m., the Physician's Orders indicated the following: Electrocardiogram (a simple, painless test that records the electrical activity of the heart, helping doctors assess heart health and identify potential problems like irregular heartbeats or heart attacks); complete blood count (a blood test that measures the components of blood, including red blood cells, white blood cells, and platelets); basic metabolic panel (a common blood test that assesses your body's metabolism, fluid balance [the body's ability to maintain a stable internal environment by regulating the amount and distribution of fluids, ensuring proper hydration and electrolyte levels, and supporting vital functions like cellular metabolism and temperature regulation], and kidney function, measuring levels of glucose [sugar], electrolytes [essential minerals vital to many key functions of the body], and kidney waste products); troponin level ( found in heart muscle and usually elevated when heart muscle is damaged; Chest Xray; CT (Computed Tomography, a medical imaging technique that uses X-rays to create detailed, three-dimensional images of internal organs and structures within the body) of Head and MRI (Magnetic Resonance Imaging, an imaging technique that uses a strong magnetic field and radio waves to create detailed images of the inside of the body) of Brain. Patient 1 was roomed at 7:54 p.m. and Patient 1's MSE (Medical Screening Exam) was at 7:59 p.m.

During a review of Patient 1's ED physician Notes, dated 3/3/2025, the ED Physician's Notes indicated Patient 1's diagnosis was acute stroke (a blood clot or bleeding in the brain preventing blood from reaching the brain). Patient 1's MRI of the brain ordered on 3/3/2025 indicated findings of "Acute CVA (cerebrovascular accident, a bleed in the brain)."

During a concurrent interview and record review on 4/3/2025 with ADED, Patient 1's Emergency Department Patient Care Timeline, dated 3/3/2025, was reviewed. The ADED confirmed there was no documentation of a Registered Nurse (RN) in Triage (a preliminary nursing assessment to determine urgency of need for treatment), nor was there Physician assessment. The ADED confirmed lab (laboratory) and imaging orders for Patient 1. The ADED confirmed there was no documentation of "Stroke Alert (a medical notification that indicates a patient may be experiencing a stroke)," called by Triage RN and no "Code Stroke (a hospital protocol, an emergency alert, initiated when a patient is suspected of having a stroke)," called by the physician.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Medical Screening Examination Treatment and Transfer," dated 2/16/2024, the P&P indicated "the facility will provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the Emergency Department (ED) to determine if an Emergency Medical Condition (EMC) exists. A MSE will be provided within the capabilities and capacity of the emergency department." "If after the MSE it is determined that the individual has an EMC the hospital must within its capability and capacity to provide further medical examination and treatment required to stabilize the EMC."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Management of Code Stroke Alert and Code Stroke in the Emergency Department," dated 11/2024, the P&P indicated "overall goal of Stroke Treatment in the Emergency Department are rapid safe and appropriate assessment and treatment of patients exhibiting signs and symptoms concerning for acute stroke" and "Stroke Alert is level 1 activation by nursing after rapid assessment of patient identified to have signs and symptoms potential for stroke with a last known well time of 24 hours prior" and "Code Stroke is level two activation decided by the physician after Stroke Alert and prompt quick medical assessment of the patient."