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Based on interviews, medical record review, review of Facility #1's Emergency Department (ED) logbook, and review of facility policies, it was determined Facility #1 failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #3) that presented to Facility #1's ED for an Emergency Medical Condition. Record reviews from Facility #1, Facility #2, and Facility #3 and interviews revealed Patient #3 presented to Facility #1's ED on 10/05/17 at 10:46 AM with complaints of "had seizure at [Facility #3] this morning." Patient #3 was provided with a Medical Screening Exam by Physician #1 at 10:50 AM. Laboratory studies and a chest x-ray were conducted and Patient #3 was discharged back to Facility #3 at 1:58 PM with a diagnosis of "seizure disorder." There was no documented evidence any Neurological diagnostic testing was conducted or any other medical intervention provided. Patient #3 returned to Facility #1 via Emergency Medical Services (EMS) on 10/05/17 at 7:14 PM, approximately five (5) hours later, with the same complaint, "Altered Mental Status and Seizures." Facility #1 transferred Patient #3 to Facility #2 on 10/05/17 at 10:32 PM due to "altered mental status." Facility #2 diagnosed Patient #3 with "multiple ischemic strokes (a loss of blood to the brain caused by a blocked artery) and Encephalopathy secondary to multiple ischemic strokes (malfunction of the brain due to loss of blood flow)." Facility #2 discharged Patient #3 back to Facility #3 on 10/18/17 with palliative care in place. Patient #3 expired on 10/28/17 due to Cerebral Infarction (an ischemic stroke).

Based on interviews, medical record review, review of Facility #1's Emergency Department (ED) logbook, and review of facility policies, it was determined Facility #1 failed to ensure stabilizing medical treatment was provided for one (1) of twenty (20) sampled patients (Patient #3) that presented to Facility #1's ED for an Emergency Medical Condition. Record reviews from Facility #1, Facility #2, and Facility #3 and interviews revealed Patient #3 presented to Facility #1's ED on 10/05/17 at 10:46 AM with complaints of "had seizure at [Facility #3] this morning." Patient #3 was provided with a Medical Screening Exam by Physician #1 at 10:50 AM, laboratory studies and a chest x-ray were conducted, and Patient #3 was discharged back to Facility #3 at 1:58 PM with a diagnosis of "seizure disorder." There was no documented evidence any Neurological diagnostic testing was conducted or any other medical intervention provided.

Patient #3 returned to Facility #1 via Emergency Medical Services (EMS) on 10/05/17 at 7:14 PM, approximately five hours later, with the same complaint, "Altered Mental Status and Seizures." Facility #1 transferred Patient #3 to Facility #2 on 10/05/17 at 10:32 PM due to "altered mental status." Facility #2 diagnosed Patient #3 with "multiple ischemic strokes (a loss of blood to the brain caused by a blocked artery) and Encephalopathy secondary to multiple ischemic strokes (malfunction of the brain due to loss of blood flow)." Facility #2 discharged Patient #3 back to Facility #3 on 10/18/17 with palliative care in place. Patient #3 expired on 10/28/17 due to Cerebral Infarction (an ischemic stroke).

The findings include:

Review of Facility #1's policy titled "The Emergency Medical Treatment and Active Labor Act (EMTALA)," revised February 2009, revealed all patients presenting to the facility's Emergency Department seeking emergency care, would be accepted and evaluated regardless of the patient's ability to pay. All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the facility to reach a diagnosis. Continued review of the policy revealed if the medical screening examination revealed that an emergency medical condition existed, the facility would then provide all such patients with uniform treatment necessary to stabilize their condition. The facility would provide either within the staff and facilities available at the facility, for such further medical and such treatment as would be required to stabilize the medical condition or transfer the individual to another facility in accordance with the transfer guidelines of EMTALA.

Review of the facility's "ED Code Stroke Process," undated, revealed in the event of a stroke the facility should assign the patient to a bed and when possible triage straight to x-ray and the following should be done: red code stroke box obtained and code stroke tracker form begun, report received by ED nurse and provider, code stroke order set entered into system, patient to CT (computed tomography) for a non-contrast CT scan (within 25 minutes of arrival), CT interpretation 45 minutes from door time, determine type of stroke (ischemic vs hemorrhagic), complete Dysphagia screening, consider contraindications to IV tPA (tissue Plasminogen Activator - a strong clot dissolving medicine), activase ordered, neurologist contacted, and transfer arranged.

Review of the credentialing file for Physician #1 on 09/26/18 revealed Physician #1 was appointed privileges on 10/24/16 at Facility #1; however, there was no documented evidence the facility oriented/educated Physician #1 on their EMTALA policies.

Review of Facility #1's ED logbook revealed Patient #3 presented on 10/05/17 at 10:44 AM. The documented reason for the visit was "Seizure." Continued review of the logbook revealed Patient #3 was discharged on 10/05/17 at 4:30 PM with a disposition of "back to [long-term care]." Further review of the ED logbook revealed Patient #3 presented on 10/05/17 at 7:55 PM, approximately three and a half (3.5) hours later with "Altered Mental Status and Seizures." According to the logbook, the facility transferred Patient #3 on 10/05/17 at 11:37 PM to "another acute care [facility]."

Review of the medical record from Facility #3 revealed Patient #3 was assessed by Advanced Practice Registered Nurse (APRN) #1 on 10/05/17 at 10:27 AM for "nurse reports [Patient #3] had a seizure this am then followed by another questionable seizure." Patient #3 was "not acting normal and continues to have a clinched mouth." Patient #3's vital signs were as follows: pulse rate of 84, blood pressure of 112/70, and respiratory rate of 18. APRN #1 found Patient #3 to be lying in bed with "mouth clinched and having rapid eye movement. [Patient #3] does not respond to questions or have eye contact." APRN #1 diagnosed Patient #3 with "Unspecified Convulsions, Altered Mental Status and Unspecified Speech Disturbances with a plan to send to "[Facility #1] for evaluation."

Review of the Emergency Medical Services (EMS) patient care record revealed on 10/05/17 at approximately 10:34 AM, EMS assessed Patient #3 at Facility #3 and documented that the patient had "altered mental status with a chief complaint of seizure." According to the report, Patient #3 was "responsive to pain" and was placed in the ambulance with the right leg extended and patient was moving the left leg. The record stated the patient's left arm was contracted and the patient was not moving the right arm. Continued review of the EMS record revealed EMS staff documented that "patient requires ambulance due to altered [level of conscience]." In addition, the EMS initial assessment of Patient #3 was documented with Patient #3's mental status as confused, left pupil 2 mm (millimeters), and the right pupil was 2 mm and constricted. The assessment further revealed the left arm was assessed as "other," right arm with weakness, and right leg as "other." The report stated Patient #3's care was transferred to Facility #1's staff on 10/05/17 at 10:44 AM.

Review of Facility #1's medical record for Patient #3 revealed the facility documented Patient #3's arrival time on 10/05/17 at 10:46 AM and triaged Patient #3 at 10:48 AM for a chief complaint of "had a seizure at the [Facility #3] this am." Nursing staff documented that Patient #3 was not oriented to place and the patient's vital signs were as follows: pulse rate of 60, and respiratory rate of 18. There was no documented evidence of a blood pressure taken at triage.

Review of the "ED Notes" dated 10/05/17 at 10:50 AM, revealed Physician #1 assessed Patient #3 and documented that the patient presented with seizures, the onset prior to arrival with a single episode with no postictal symptoms. Continued review of the documentation revealed on "Physical Exam," Physician #1 documented that Patient #3 was alert and in no acute distress, with cooperative and appropriate mood and affect. There was no documented evidence that Physician #1 performed any type of neurological exam. Physician #1 ordered laboratory studies (Complete Blood Count [CBC], Complete Metabolic Profile [CMP], urine analysis, and a chest x-ray) with no significant findings. Physician #1 documented that the Impression was "Seizure Disorder" and to discharge the patient back to [Facility #3].

Further review of Patient #3's medical record from Facility #1 revealed nursing staff assessed Patient #3 on 10/05/17 at 11:06 AM and documented that Patient #3 was disoriented to person, place, and time, and vital signs were as follows: pulse rate of 50, blood pressure of 156/63, and respiratory rate of 14. Continued review of the nursing assessment revealed a Neurological assessment which documented "unable to assess." Further review of the nursing documentation revealed nursing staff documented that an IV was placed in Patient #3's right wrist on 10/05/17 at 11:28 AM and blood was drawn at that time. Nursing staff rounded on Patient #3 at 11:54 AM with vital signs as follows: pulse rate of 52, respiratory rate of 18, and blood pressure of 160/62. It was documented that nursing staff was unable to assess pain at that time. In addition, nursing staff rounded on Patient #3 at 12:12 PM with vital signs of 96.1 temperature, pulse rate of 56, respiratory rate of 18, and blood pressure of 148/71. At 1:37 PM the patient's vital signs were documented as pulse of 60, respiratory rate of 23, and blood pressure of 170/61. At 1:47 PM the patient's vital signs were documented as temperature 99.6 degrees, pulse rate of 65, respiratory rate of 19, and blood pressure of 170/61. Nursing staff also documented discharge vital signs at 2:02 PM of pulse rate of 57, respiratory rate of 19, and blood pressure of 110/42. The nursing discharge note stated, "[Patient #3] discharged home. Informed to follow-up with [primary care provider] and return to ED as needed, report given to [nurse at Facility #3], nurse verbalized understanding and IV [discontinued] before discharge."

Review of the Emergency Medical Services (EMS) patient care record revealed on 10/05/17 at approximately 5:30 PM, EMS assessed Patient #3 at Facility #3 and documented that the patient had "mental disorder with a chief complaint of possible stroke." According to the report, Patient #3 was "confused and had edema and weakness bilaterally in upper and lower extremities and the Cincinnati Stroke Scale was performed." Continued review of the EMS record revealed EMS staff documented "patient requires ambulance transport due to Emergency possible stroke." In addition, the EMS initial assessment of Patient #3 was documented with Patient #3's mental status as "confused," and neurological assessment as "left and right sided weakness." The report stated Patient #3's care was transferred to Facility #1's staff on 10/05/17 at 6:01 PM.

Review of the medical record for Patient #3's second visit to the ED revealed Patient #3 arrived at the facility on 10/05/17 at 6:09 PM via EMS and was triaged at 6:09 PM for "[Patient #3] d/c to [Facility #3] this afternoon from this ED, per [Facility #3] patient with [altered mental status] and sent here for evaluation and admission per EMS." Nursing staff documented that Patient #3 was not oriented to place and the patient's vital signs were as follows: pulse rate of 86, respiratory rate of 18, and blood pressure of 163/83.

Review of the "ED Notes" dated 10/05/17 at 6:47 PM, revealed Physician #1 assessed Patient #3 and documented that the patient presented with altered mental status, the onset prior to arrival with the course/duration of symptoms as constant, the character of the symptoms as foaming at mouth and right side weakness. The degree at onset and present was minimal. Continued review of the documentation revealed on physical exam, Physician #1 documented that Patient #3 was alert and in no acute distress, with cooperative and appropriate mood and affect, Musculoskeletal was documented as patient unable to follow commands but when trying to passively move extremities patient will resist, and Neurological was "nonverbal." Physician #1 ordered laboratory studies (CBC, CMP, urine analysis, and a CT scan) with no significant findings. Physician #1 documented that the impression was "Altered Mental Status" and transferred the patient's care to Physician #2 at 8:35 PM. Physician #2 documented his Impression as "Altered Mental Status and Seizures Disorder" and transferred care to "[Facility #2] with Patient #3's condition as "stable." The facility failed to provide a complete medical screening exam. A neurology exam was not completed and as a result, the patient was also not stabilized.

Further review of Patient #3's medical record from Facility #1 revealed nursing staff documented an initial nursing assessment performed on 10/05/17 at 6:15 PM; however, there was no other documented evidence of nursing staff assessing Patient #3 from 6:15 PM until Patient #3 was discharged with "time unknown." Review of the transfer paperwork revealed Facility #2 accepted Patient #3 at 10:00 PM and nursing staff gave report at 10:07 PM.

Review of Patient #3's medical record from Facility #2 revealed on 10/06/17 at 12:28 AM, the facility admitted Patient #3 with a diagnosis of "altered mental status." Review of Patient #3's discharge summary revealed Patient #3 had a CT scan conducted which showed Ventriculomegaly (when structures within the brain become larger than normal), rule out Hydrocephalus with no change from prior CT. A Magnetic Resonance Imaging (MRI) scan was performed that found multiple small foci of acute ischemic changes in the left occipital pons and posterior fossa with atrophy and chronic ischemic changes. Patient #3's prognosis was documented as poor and his/her respiratory status declined on 10/09/17 with oxygen saturation at 96 % on ten (10) liters of oxygen. Patient #3 was placed on comfort measures only and at the time of discharge, Patient #3 was in no distress and not responsive to sternal rub (application of painful stimulus with the knuckles of a closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli). Continued review of the medical record revealed Patient #3 was discharged from Facility #2 on 10/18/17 with diagnoses of Multiple Ischemic Strokes, Encephalopathy Secondary to Multiple Ischemic Strokes, Acute Hypoxic Respiratory Failure, and Presumed Aspiration.

Further review of Patient #3's medical record from Facility #3 revealed on 10/28/17 at 6:38 AM Patient #3 was found with no audible or visible signs of life.

Interview with APRN #1 on 09/25/18 at 9:15 AM and on 09/27/18 at 9:30 AM revealed she was the Primary Care Provider at Facility #3 for Patient #3. APRN #1 stated she assessed Patient #3 on the morning of 10/05/17 and noted changes in the patient's mental status at that time. APRN #1 stated she documented those changes and also called report to Facility #1 and informed them of her concerns of the mental status changes aside from the seizure. APRN #1 stated when no interventions were performed from the first visit to Facility #1's ED, she attempted to get Patient #3 transported to the ED at Facility #2; however, EMS would only transport an emergency patient to the nearest ED, which happened to be Facility #1 again.

Interview with the ED Director on 09/26/18 at 11:15 AM and on 09/18/18 at 10:45 AM revealed he did not recall Patient #3, and Physician #1 was a locum tenens (a physician who fills in on a temporary basis) and no longer worked at the facility. The ED Director further stated that the RN that provided care for Patient #3 on both visits was a "traveling nurse" and was no longer working at the facility either. Continued interview with the ED Director revealed there was no set person in the ED for another facility to give report to in the ED. The ED Director stated it could be the triage RN, an RN at the desk, the Ward Clerk, or an ED Tech. The ED Director stated he was unaware if this posed a problem or not. The ED Director stated that after reviewing Patient #3's medical record, he agreed that nursing staff should provide care and should make rounds on each patient in the ED every hour if not more often. Further interview with the ED Director revealed that all ED nursing staff were trained annually on EMTALA requirements, but he was not knowledgeable of how/when ED physicians were trained.