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Based on review of facility policies, review of Medical Staff Bylaws, medical record reviews, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment within its capabilities for 1 patient (Patient #3) with a Cerebrovascular Accident (Stroke/CVA) of 32 patients reviewed. The facility's failure resulted in Patient #3's Emergency Medical Condition (EMC) not being diagnosed or treated until the next day at another hospital.

The findings included:

Patient #3 presented to the Emergency Department (ED) at Hospital A on 7/6/2022 at 9:28 AM complaining of possible heat stroke and generalized weakness. The patient's daughter notified the ED doctor the patient had been assessed earlier on 7/6/2022 at a local urgent care clinic where the provider had suspected the patient of having a possible stroke. The patient's daughter requested a Computerized Tomography (CT scan is a computer assisted X-Ray imaging procedure) scan of the patient's head to rule out a stroke, but the ED doctor refused to provide a CT scan. The patient's daughter stated she had notified the ED doctor that the physician at the urgent care clinic had recommended a CT scan be done to rule out a stroke, but a CT scan was not done. Patient #3 was discharged home from Hospital A with diagnosis of Heat Exhaustion on 7/6/2022 at 10:53 AM. The patient was transported to Hospital B the next day on 7/7/2022 at 1:14 PM for complaint of tiredness and confusion for 2 days. A CT scan at Hospital B of Patient #3's head on 7/7/2022 revealed he had a subacute CVA.

Refer to:
A-2406
A-2407

Based on policy reviews, review of Medical Staff Bylaws, medical record reviews, and interviews the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital to diagnose the Emergency Medical Condition (EMC) of 1 (Patient #3) patient of 32 patients reviewed. This failure led to Patient #3's EMC not being diagnosed and treated at Hospital A.

The findings included:

Review of facility policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - Tennessee Medical Screening Examination & Stabilization" approved 9/2021 revealed, "...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and...the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition...then an appropriate MSE, within the capabilities of the Hospital's DED...including ancillary services routinely available...shall be performed...A hospital must provide an appropriate MSE within the capabilities of hospital's emergency department, including ancillary services routinely available to the DED... "

Review of the facility's "Medical Staff Rules and Regulations - 2021" approved 9/2021 revealed, "...A physician/APP [Advanced Practice Provider] or qualified medical person provides medical screening and determines the scope of assessment and care for patients in need of emergency care..."

Review of the Hospital A's medical record revealed Patient #3 presented to the Emergency Department (ED) on 7/6/2022 at 9:28 AM for complaint of "...OVER HEATED YESTERDAY SENT BY FASTPACE [an urgent care clinic]..." Review of the Emergency Provider Report dated 7/6/2022 at 9:31 AM revealed, "...states he worked in the heat over 100F (100 degrees Fahrenheit) yesterday. Notes he has some generalized weakness. States he has had some difficulty concentrating but feels somewhat better now...Neurologic Oriented X3 [oriented to person, time, and place], Speech NL [normal], No motor deficits, No sensory deficits, CN ll-Xll [cranial nerves 2-12) intact, Cerebellar NL, Gait NL...Normal neuro exam. No cerebellar changes and gait is normal. Head CT [computerized tomography is computer assisted x-ray imaging] is not indicated. No evidence of stroke or TIA [Transient Ischemic Attack, brief stroke symptoms]. Patient is alert and oriented with normal mental status. He states that he feels better after IV [intravenous] fluids. No indication for admission. Will d/c [discharge]..." Continued review revealed the patient had a Chemistry Panel (blood tests) performed and was treated with 1 liter of normal saline IV solution. There is no documentation of any other diagnostic tests being provided. Continued review revealed the patient was diagnosed with Heat Exhaustion and discharged home on 7/6/2022 at 10:53 AM.

Review of Patient #3's medical records from Hospital B revealed he presented there on 7/7/2022 at 1:14 PM for complaint of tiredness and confusion for 2 days. Review of a CT scan of Patient #3's head dated 7/7/2022 at 2:45 PM revealed, "...No acute intracranial hemorrhage or other acute findings. A hypodense lesion involving the right basal ganglia [bottom of brain] region and internal capsule likely reflect a subacute infarct [stroke]...Findings suspicious for old lacunar [stroke area located inside the deep tissues of the brain] infarct in the left caudate [structure in middle of brain] head region..." Continued review of the physician's notes dated 7/7/2022 revealed, "...Acute CVA [cerebrovascular attack/stroke]...new and requires workup...Pt appears to have had a subacute CVA...discussed with neurologist and start on Plavix [blood thinner] and aspirin and will see in office in few days..."

Review of Patient #3's medical records from Hospital C revealed he presented there on 7/9/2022 at 3:11 PM for complaint of headache and back pain. Review of an ED Provider's Note dated 7/9/2022 at 5:29 PM revealed, "...ischemic stroke 2 days ago...headache all day, generalized." Review of a CT of the Head report dated 7/9/2022 at 5:47 PM revealed, "...Relatively large lacunar infarct...likely subacute in nature..."

Interview with Physician #1 (MD #1) was completed by telephone on 7/28/2022 at 8:02 AM. MD #1 stated he was the doctor on duty at Hospital A on 7/6/2022 and he remembered examining and treating Patient #3 on 7/6/2022. Continued interview revealed MD #1 found the patient had no symptoms of a stroke or TIA. Continued interview revealed there was no indication for a CT scan of the patient's head and no need for additional diagnostic testing or consultation with a neurologist or other specialists. Continued interview revealed the patient had no neurological deficits, no facial drooping, his speech was clear, he was alert and oriented, and he was able to ambulate without difficulty. Continued interview revealed the only diagnostic test performed was a BMP (Basic Metabolic Panel, a blood test that measure 8 substances in the blood) and found no significant abnormalities. Continued interview revealed the patient appeared to have heat exhaustion and he was treated with IV fluids which the patient stated made him feel better. Continued interview revealed the patient did not need any additional diagnostic tests, consultations, or treatment. Continued interview revealed MD #1 assessed the patient as being stable and not having any emergency medical conditions when he was discharged home on 7/6/2022.

Telephone interview with Patient #3's daughter was completed on 7/28/2022 at 9:49 AM. Patient #3's daughter stated she had found the patient at home on 7/6/2022 having difficulty walking, weak, and confused at times. Continued interview revealed the patient had been working in high heat on 7/5/2022 and the daughter thought the patient had heat stroke from the high temperatures at his work. Continued interview revealed she took the patient to an urgent care clinic and the doctor there believed the patient possibly had a stroke and told the daughter the patient needed a CT scan of his head to rule out a stroke. Continued interview revealed she took the patient directly to Hospital A to be evaluated and to have a CT scan. Continued interview revealed the patient's daughter told the ED Physician at Hospital A the urgent care provider suspected the patient had a stroke and recommended a CT scan of his head. Continued interview revealed the doctor at Hospital A refused to do a CT scan and told the daughter the patient did not have any signs of a stroke. The daughter stated she asked the doctor at Hospital A three times to do a CT scan of the patient's head but he refused. The daughter stated the patient was given IV fluids and discharged home. The daughter stated the patient could barely walk with assistance when he left Hospital A. Continued interview revealed the patient fell at home three times over night and was forgetful and confused the next day (7/7/2022), so the daughter took him to Hospital B on 7/7/2022 to be evaluated. Continued interview revealed the patient was provided a CT scan there which showed he had a stroke. The patient's daughter stated it was too late to treat him on 7/7/2022 but he could have been treated while at Hospital A if they had diagnosed him in time. Continued interview revealed the patient was discharged home from Hospital B on 7/7/2022 and continued to have problems which included a headache and right flank pain on 7/9/2022. Continued interview revealed the patient was transported to Hospital C on 7/9/2022 where they did another CT scan and confirmed he had a stroke. Continued interview revealed the patient was not admitted to Hospital C on 7/9/2022. Continued interview revealed the patient was currently waiting to see a neurologist for follow-up treatment.

Interview on 7/28/2022 at 3:30 PM in the Quality Conference room with the Director of Quality Standards revealed the Hospital A had the capability to perform CT scans on 7/6/2022. Continued interview revealed Hospital A also had a neurologist on-call available 24/7 by telemedicine if needed. Continued interview confirmed Patient #3 had no CT scans performed and there were not any consultations with a neurologist or other specialists on 7/6/2022.

Based on policy reviews, medical record reviews, and interviews the facility failed to provide stabilizing treatment within the capabilities of the hospital to treat the Emergency Medical Condition (EMC) of 1 (Patient #3) patient of 32 patients reviewed. This failure led to Patient #3's Cerebrovascular Accident (CVA/Stroke) not being diagnosed and treated at Hospital A.

The findings included:

Review of facility policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) - Tennessee Medical Screening Examination & Stabilization" approved 9/2021 revealed, "...if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility..."

Review of the Hospital A's medical record revealed Patient #3 presented to the Emergency Department (ED) on 7/6/2022 at 9:28 AM for complaint of "...OVER HEATED YESTERDAY SENT BY FASTPACE [an urgent care clinic]..." Review of the Emergency Provider Report dated 7/6/2022 at 9:31 AM revealed, "...states he worked in the heat over 100F (100 degrees Fahrenheit) yesterday. Notes he has some generalized weakness. States he has had some difficulty concentrating but feels somewhat better now...Neurologic Oriented X3 [oriented to person, time, and place], Speech NL [normal], No motor deficits, No sensory deficits, CN ll-Xll [cranial nerves 2-12) intact, Cerebellar NL, Gait NL...Normal neuro exam. No cerebellar changes and gait is normal. Head CT [computerized tomography is computer assisted x-ray imaging] is not indicated. No evidence of stroke or TIA [Transient Ischemic Attack, brief stroke symptoms]. Patient is alert and oriented with normal mental status. He states that he feels better after IV [intravenous] fluids. No indication for admission. Will d/c [discharge]..." Continued review revealed the patient had a Chemistry Panel (blood tests) performed and was treated with 1 liter of normal saline IV solution. There was no documentation of any other diagnostic tests being provided. There was no documentation of the patient being provided any other treatments. There was no documentation of the patient being provided any consults with neurologists or other specialists. Continued review revealed the patient was diagnosed with Heat Exhaustion and discharged home on 7/6/2022 at 10:53 AM.

Review of Patient #3's medical records from Hospital B revealed he presented there on 7/7/2022 at 1:14 PM for complaint of tiredness and confusion for 2 days. Review of ED Provider Notes dated 7/7/2022 at 5:40 PM revealed, "...Pt [patient] evidently has had some confusion over the last 1 to 2 weeks and had got worse 2 days ago. Has had a mild headache but no vomiting. Denies one sided weakness but has felt tired and fatigued..." Review of the physician's physical exam notes revealed, "...No focal deficits present...alert and oriented to person, place and time...good strength in all extremities..." Review of a CT scan of Patient #3's head dated 7/7/2022 at 2:45 PM revealed, "...No acute intracranial hemorrhage or other acute findings. A hypodense lesion involving the right basal ganglia [bottom of brain] region and internal capsule likely reflect a subacute infarct [stroke]...Findings suspicious for old lacunar [stroke area located inside the deep tissues of the brain] infarct in the left caudate [structure in middle of brain] head region..." Continued review of the physician's notes dated 7/7/2022 revealed, "...Acute CVA [cerebrovascular attack/stroke]...new and requires workup...Pt appears to have had a subacute CVA...discussed with neurologist and start on Plavix [blood thinner] and aspirin and will see in office in few days..." Continued review revealed the patient was discharged home on 7/7/2022 at 5:45 PM.

Review of Patient #3's medical records from Hospital C revealed he presented there on 7/9/2022 at 3:11 PM for complaint of headache and back pain. Review of an ED Provider's Note dated 7/9/2022 at 5:29 PM revealed, "...ischemic stroke 2 days ago...headache all day, generalized. His pressures have been in the 200/90s [normal blood pressure is below 130/80]...Pt was diagnosed with Carotid DZ [disease] and is currently on Plavix...Pt is also having right flank pain...He is alert and oriented to person, place, and time...is ambulatory with minimal assistance..." Review of a CT of the Head report dated 7/9/2022 at 5:47 PM revealed, "...Relatively large lacunar infarct...likely subacute in nature..." Continued review revealed the patient was discharged on 7/9/2022 at 9:52 PM.

Interview with Physician #1 (MD #1) was completed by telephone on 7/28/2022 at 8:02 AM. MD #1 stated he was the doctor on duty at Hospital A on 7/6/2022 and he remembered examining and treating Patient #3 on 7/6/2022. Continued interview revealed MD #1 found the patient had no symptoms of a stroke or TIA. Continued interview revealed there was no indication for a CT scan of the patient's head and no need for additional diagnostic testing or consultation with a neurologist or other specialists. Continued interview revealed the patient had no neurological deficits, no facial drooping, his speech was clear, he was alert and oriented, and he was able to ambulate without difficulty. Continued interview revealed the only diagnostic test performed was a BMP (Basic Metabolic Panel, a blood test that measure 8 substances in the blood) and found no significant abnormalities. Continued review revealed the patient appeared to have heat exhaustion and he was treated with IV fluids which the patient stated made him feel better. Continued interview revealed MD #1 assessed the patient as being stable and not having any emergency medical conditions when he was discharged home on 7/6/2022.

Telephone interview with Patient #3's daughter was completed on 7/28/2022 at 9:49 AM. Patient #3's daughter stated she had found the patient at home on 7/6/2022 having difficulty walking, weak, and confused at times. Continued interview revealed the patient had been working in high heat on 7/5/2022 and the daughter thought the patient had heat stroke from the high temperatures at his work. Continued interview revealed she took the patient to an urgent care clinic and the doctor there believed the patient might have had a stroke and told the daughter the patient needed a CT scan of his head to rule out a stroke. Continued interview revealed she took the patient directly to Hospital A to be evaluated and to have a CT scan. Continued interview revealed the daughter told the ED physician at Hospital A of the urgent care provider's suspicion of the patient having a stroke and recommending a CT scan of his head. Continued interview revealed the doctor at Hospital A refused to do a CT scan and told the daughter the patient did not have any signs of a stroke. The daughter stated she asked the doctor at Hospital A three times to do a CT scan of the patient's head, but the doctor refused. The daughter stated the patient was given IV fluids and discharged home. The daughter stated the patient could barely walk with assistance when he left Hospital A. Continued interview revealed the patient fell at home three times over night and was forgetful and confused the next day (7/7/2022), so she took him to Hospital B on 7/7/2022 to be evaluated. Continued interview revealed the patient was provided a CT scan there which revealed the patient had a stroke. The daughter stated if Patient #3 had been diagnosed soon enough his stroke could have been treated. The patient's daughter stated it was too late to treat him on 7/7/2022 but he could have been treated while at Hospital A on 7/6/2022 if they had diagnosed him in time. Continued interview revealed the patient was discharged home from Hospital B on 7/7/2022 and continued to have problems which included a headache and right flank pain on 7/9/2022. Continued interview revealed the patient was transported to Hospital C on 7/9/2022 where they did another CT scan and confirmed he had a stroke. Continued interview revealed the patient was not admitted to Hospital C on 7/9/2022. Continued interview revealed the patient was currently waiting to see a neurologist for follow-up treatment.

Interview on 7/28/2022 at 3:30 PM in the Quality Conference room with the Director of Quality Standards revealed Hospital A's ED had the capability to perform CT scans on 7/6/2022 and had a neurologist on-call available 24/7 by telemedicine if needed. Continued interview confirmed Patient #3 was not provided any CT scans or any consultations with a neurologist or other specialists.