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Based on review of policies/procedures, documentation, and patient medical records, the Critical Access Hospital (CAH) staff failed to follow their policy to ensure that every patient who presents to the CAH's Emergency Room (ER) receives an appropriate Medical Screening Examination (MSE) for 1 of 24 closed medical records reviewed between 3/15/10 and 8/3/10 (Patient # 1) The CAH had an average of 100 ER visits per month.

Findings Included:

1. Review of the Shenandoah Medical Center policy: Cobra-EMTALA dated 1/15/2010 stated in part: "Any individual who is not otherwise a patient of the hospital, shall be provided an appropriate medical screening examination (MSE) within the capabilities of the Emergency Room... The hospital will provide an appropriate medical screening examination and necessary stabilizing treatment for all patients with emergency medical conditions...."

The CAH staff did not follow this policy and failed to provide Patient #1 with an appropriate medical screening exam.

2. Review of the July 22, 2010 medical record revealed the attending Physician Assistant (PA) dictated the following information, in part, regarding Patient #1.

The patient presented to the Emergency Room (ER) after experiencing a "sudden onset of dysfunction or change in sensation and coordination" in the right upper extremity. The patient reported that around 4:00 PM on July 22, 2010, while driving, "her arm just did not want to work like it normally would", the symptoms occurred suddenly, were slowly getting better, and were almost gone upon arrival to the ER. The patient denied any other type of symptomatic problems and stated nothing like this had ever happened to her before. The patient denied any headache, vision changes, shortness of breath, chest pain or any other similar symptoms. The symptoms seemed isolated to her right upper extremity. Since the symptoms had not completely resolved the PA ordered the following laboratory tests: cardiac enzymes, Troponin level, complete blood count, and a blood glucose level. The PA documented "...At this time it is unclear as to the specific cause of these overall symptoms in her right upper extremity. She did state that she just did not feel right and she did not feel right in writing her name on her discharge sheet, but overall she was really not complaining of any other symptoms. Obviously this did still concern her a little bit and does raise our suspicion, and if she is having any degree of symptoms in the morning, she is to contact her regular doctor and set up an appointment as soon as possible. It was stressed to not only her but her husband that if she has any worsening symptoms, which would also include her arm, but also chest pain, shortness of breath, mental status changes or any other concerning features, she is to come out to the ER immediately for reevaluation ...." The patient's past medical history and diagnoses included hypertension, hypercholesterolemia, and smoking approximately 1 pack of cigarettes per day (known stroke risk factors according to the American Heart Association).

3. According to the statutorily mandated QIO review performed on 8/18/2010, the hospital failed to provide patient # 1 with an appropriate and sufficient medical screening examination. Patient # 1 presented to the ED with symptoms of an acute neurovascular event and required further workup and referral to a stroke center.
Refer to tag C 2406 for further information and details.

Based on review of policies/procedures, documentation, patient medical records, and staff interviews, the Critical Access Hospital (CAH) failed to follow CAH policy to ensure that every patient who presents to the CAH's Emergency Room (ER) receives an appropriate Medical Screening Examination (MSE) for 1 of 24 closed medical records reviewed between 3/15/10 and 8/3/10 (Patient # 1). The CAH had an average of 100 ER visits per month.

Findings Included:

1. Review of CAH policy titled Cobra-EMTALA dated 1/15/2010 revealed, in part: "Any individual who is not otherwise a patient of the hospital, shall be provided an appropriate medical screening examination (MSE) within the capabilities of the Emergency Room... The hospital will provide an appropriate medical screening examination and necessary stabilizing treatment for all patients with emergency medical conditions...."

The CAH staff did not follow this policy and failed to provide Patient #1 with an appropriate medical screening exam.

2. Review of the July 22, 2010 medical record revealed the attending Physician Assistant (PA) dictated the following information, in part, regarding Patient #1.

The patient presented to the Emergency Room (ER) after experiencing a "sudden onset of dysfunction or change in sensation and coordination" in the right upper extremity. The patient reported that around 4:00 PM on July 22, 2010, while driving, "her arm just did not want to work like it normally would", the symptoms occurred suddenly, were slowly getting better, and were almost gone upon arrival to the ER. The patient denied any other type of symptomatic problems and stated nothing like this had ever happened to her before. The patient denied any headache, vision changes, shortness of breath, chest pain or any other similar symptoms. The symptoms seemed isolated to her right upper extremity. Since the symptoms had not completely resolved the PA ordered the following laboratory tests: cardiac enzymes, Troponin level, complete blood count, and a blood glucose level. The PA documented "...At this time it is unclear as to the specific cause of these overall symptoms in her right upper extremity. She did state that she just did not feel right and she did not feel right in writing her name on her discharge sheet, but overall she was really not complaining of any other symptoms. Obviously this did still concern her a little bit and does raise our suspicion, and if she is having any degree of symptoms in the morning, she is to contact her regular doctor and set up an appointment as soon as possible. It was stressed to not only her but her husband that if she has any worsening symptoms, which would also include her arm, but also chest pain, shortness of breath, mental status changes or any other concerning features, she is to come out to the ER immediately for reevaluation ...." The patient's past medical history and diagnoses included hypertension, hypercholesterolemia, and smoking approximately 1 pack of cigarettes per day (known stroke risk factors according to the American Heart Association).

3. At 9:30 PM Staff A, RN documented the Physician Assistant (PA) came back in the room to re-evaluate patient # 1, discuss labs, review the plan of care, and provide discharge instructions. Staff A documented that patient # 1 reported that writing her name still did not feel normal and that the PA told the patient that she should return to the ER or follow up with her family physician if she experienced any worsening or progression of her symptoms.
Staff A documented that patient # 1's spouse returned to ER at 11:05 PM and expressed concern to the PA, regarding his lack of findings related to patient # 1's symptoms and that his spouse was anxious about this. Staff A documented that the PA reiterated the discharge instructions and also discussed the potential need for an MRI as an outpatient.

4. During a phone interview on 8/9/10 at 1:00 PM, the Physician Assistant (PA)confirmed that he provided care to patient #1 on 7/22/2010 and stated the patient presented at the ER, about 5 hours after the onset of symptoms and, by that time, her symptoms were almost gone. The patient told him that while driving, her arm suddenly felt different and didn't want to work right. That her arm wasn't coordinating right. She said her upper arm did not feel quite normal yet but was not as bad as while she was driving around 4:00 PM.

The PA reported the exam he completed provided no conclusion as to what was going on with the patient. The Patient's history of hypertension (high blood pressure), smoking, and her age made him think something was going on in the brain. However, her neuro exam was within normal limits. Her finger dexterity and coordination were good, she maintained a normal gait, no weakness was noted in the upper or lower extremities, and her eyes reacted to light normally.

The Patient told him that she sensed something was different with her hand, the PA reiterated that his exam did not confirm anything out of the normal. The Patient told him that the symptoms were almost gone and she felt better.

The PA explained that when he wrote, "raised our suspicions" ("...She did state that she just did not feel right and she did not feel right in writing her name on her discharge sheet, but overall she was really not complaining of any other symptoms. Obviously this did still concern her a little bit and does raise our suspicion ...") in the medical record, he meant as of now (the time of the ER visit) her neuro systems were within normal limits but the Patient knows her own body best.

The PA confirmed that he did not review Patient #1's symptoms and history with the on-call Physician or pursue further testing, such as a CT scan because he felt the patient was not exhibiting active symptoms at the time of the neurological exam.

5. During a phone interview on 8/10/10 at 11:30 AM, Staff A, RN stated Patient #1 walked into the ER and explained her right arm "didn't feel right." She stated when writing her name the pen didn't feel right and her signature wasn't the same as before.

Staff A stated that patient # 1 walked to the ER room, undressed and put on a gown without difficulty. Patient #1 stated they had just moved and was moving and emptying boxes in the garage, when she noticed her right arm just didn't feel right.

Staff A stated she told the PA this information when he entered patient # 1's room and that he initiated a neuro exam and ordered labs. Staff A said that the PA explained the lab results to patient # 1 and said if the symptoms return, she should immediately return to ER.

After discharge, the Patient's husband returned to the ER and visited with the PA. Staff A overheard part of the conversation between the PA and the Patient which included an explanation of the PA's findings and if she experienced any increase in symptoms to return to the ER. He also told the Patient to report this to her Primary Care Physician.

6. During an interview on 8/6/10 at 8:35 AM, the physician on call to the Emergency Department on 7/22/10 stated, that he would not have expected to be called. The on-call physician said, "The chart shows a fairly normal exam, short lived symptoms for this patient." When asked if appropriate care had been given the on-call physician stated, "Probably, she probably needed to see someone else in the future.... The patients ' symptoms could be something or they might be nothing."

7. During an interview on 8/6/10 at 8:20 AM the Chief Nursing Officer (CNO) stated the hospital lacked a Stroke protocol to follow when a patient presents with stroke symptoms. The CNO stated the attending PA determines when to call the on-call Physician to review a case or to request that the on-call Physician come to the ER. The CNO confirmed the hospital has the capability to perform CT scans and staff are on call for emergencies.

8. According to the statutorily mandated QIO review performed on 8/18/2010, the hospital failed to provide patient # 1 with an appropriate and sufficient medical screening examination. Patient # 1 presented to the ED with symptoms of an acute neurovascular event and required further workup and referral to a stroke center.

9. Review of Patient #1's medical record from a second hospital (Hospital B) showed that approximately 24 hours after discharge from Shenandoah Medical Center's ER the patient presented to Hospital B's Emergency Department and was admitted for treatment of a stroke.