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Based on hospital policy review and medical record reviews, the hospital failed to comply with 42 CFR §489.24 when the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed; and to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 13 sampled patients who presented to the hospital's DED with an EMC and was discharged. (Patient #22)

The findings include:

~ Cross refer to 489.24(r) and 489.24(c) Medical Screening Examination - Tag A2406.

and

~ Cross refer to 489.24(d)(1-3), Stabilizing Treatment - Tag A2407.

Based on hospital policy review and medical record reviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 13 sampled patients who presented to the hospital's DED with an EMC and was discharged. (Patient #22)

The findings include:

Review on 02/11/2015 of current hospital policy "EMTALA (The Emergency Medical Treatment and Active Labor Act: Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions)" revised 06/2014, revealed "I. General Policy Statement... A. It is the policy of (Hospital A) to provide appropriate Medical Screening Examinations to individuals to determine wither [sic] emergency medical conditions exist and receives and refers appropriate patient transfers. 1. To determine whether an emergency medical condition exists by providing a Medical Screening Examination by a physician or other Qualified Medical Person to any individual described in Section I.B. to determine if the individual has an Emergency Medical Condition, whether or not he or she is eligible for insurance benefits and regardless of his or her ability to pay; ...B. These Policies and Procedures apply to: 1. all individuals....who present at any Dedicated Emergency Department of (Hospital A), as defined in Section II - Definitions, and request examination or treatment for a medical condition, or has such a request made on his or her behalf. ...a) Scope: All (Hospital A) employees, faculty and staff are responsible for complying with this policy. ...II. Definitions: For purposes of this Policy, the following terms and definitions apply: ...d) 'Comes to the Emergency Department' means, with respect to an individual who is not a patient, the individual either: 1. has presented at a Medical Center's Dedicated Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...g) 'Emergency Medical Condition' means: 1. a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: a. placing the health of the individual....in serous jeopardy; b. serious impairment to bodily functions; or c. serous dysfunction of any bodily organ or part; ...k) 'Medical Screening Examination' means the screening process required to determine with reasonable clinical confidence whether an Emergency Medical Condition does or does not exist. Depending on the patient's presenting symptoms, an appropriate Medical Screening Examination can involve a wide spectrum of actions ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, such as laboratory tests, x-rays, and/or other diagnostic tests and procedures. ...III. Policy Guidelines A. Medical Screening Examination. 1. (Hospital A) provides a Medical Screening Examination for every individual described in Section I.B. ...3. Within the capability of the Dedicated Emergency Department, the Medical Screening Examination determines within reasonable medical probability whether or not an Emergency Medical Condition exists. The Medical Screening Examination is performed by a physician or by a Qualified Medical Person and must be documented in the medical record. 4. The Medical Screening Examination is an ongoing process. The patient's medical record reflects continued monitoring according to the patient's needs and continues until it is determined whether or not the individual has an Emergency Medical Condition..."

Hospital A, closed DED record review on 02/11/2015 for Patient #22 revealed a 64 year old female who presented via ambulance to the DED on 09/03/2014 at 1512. Review revealed the patient was triaged by a Registered Nurse at 1519. Review of triage documentation revealed a chief complaint of Extremity Weakness, review revealed "Pt (patient) c/o (complains of) left leg heaviness and weakness that began today. Denies Pain." Review revealed initial vital signs (VS) were assessed as temperature (T) 99.2 degrees Fahrenheit (F); Pulse (P) 90; Respirations (R) 16; blood pressure (BP) 172/72; and Oxygen Saturation (SpO2) 99% on room air (RA). Review revealed an EKG (electrocardiogram) was performed at 1516. Review revealed "Sinus rhythm with short PR." Review of Past Medical History (PMH) revealed Schizoaffective Disorder, unspecified condition, Essential Hypertension (HTN), Pure hypercholesterolemia, Dizziness, and Unspecified transient cerebral ischemia et al. Review of home medications revealed Procardia-XL 30 mg (milligrams) take 1 tablet by mouth daily, Aspirin 81 mg take 1 tablet by mouth daily, and Fluphenazine Decanote 25 mg/ml injection. Review revealed the patient was assigned an Acuity Level - Urgent.

Review of MSE documentation by Resident Physician #1 dated 09/03/2014 at 1737 revealed a chief complaint of "Extremity Weakness." Review of History of Present Illness (HPI) revealed "Ms. (Patient #22 name) is a 64 y.o (year old) female with schizoaffective disorder, HTN, HLD (hyperlipidemia), and unspecified transient cerebral ischemia who presents to the ED for leg heaviness and weakness. Patient had been dancing at church this morning and came home to do laundry. Patient noticed left leg heaviness at 2pm and progress to b/l (bilateral) leg heaviness. Noticed full body weakness and sat down on bed. Did not feel dizzy or lightheaded. Denies heart palpitations, blurred vision, nausea, vomiting, or diarrhea. Currently she is completely asymptomatic and denies any other complaints." Review revealed a Past Medical History (PMH) of Schizoaffective disorder, unspecified condition; Essential hypertension, benign; Pure hypercholesterolemia; Dizziness; Unspecified transient cerebral ischemia, et al. Review of Review of Systems revealed "Constitutional: Negative for fever. HENT (Head, Eyes, Nose, Throat): Negative for congestion. Respiratory: Negative for cough. Gastrointestinal: Negative for nausea, vomiting and diarrhea. Neurological: Negative for weakness. All other systems reviewed and are negative." Review of Physical Exam revealed "Constitutional: She appears well-developed. HENT: Head: Normocephalic. Eyes: Conjunctivae are normal. Neck: Normal range of motion. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: Effort normal. Abdominal: Soft. Neurological: She is alert. Skin: Skin is warm and dry. Psychiatric: She has a normal mood and affect." Review of ED Course revealed a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Creatine Kinase (CK), and Electrocardiogram was performed. Review of Medical Decision Making (MDM) revealed "Pt care was handed off to Dr. (Resident Physician #2) at 1600. Complete history and physical and current plan have been communicated. Please refer to their note for the remainder of ED care. Patient likely having psychosomatic complaints of heaviness in legs. Patient denies headache prior to or currently. Neuro exam non focal. Doubt SAH (subarachnoid hemorrhage) or ICH (intracranial hemorrhage). No diplopia, dysarthria, ataxia, or vertigo prior to or after the event, doubt posterior circulation stroke. No postictal period or witnessed tonic clonic movements to suggest seizure. Patient denies any chest pain, dyspnea, or SOB (shortness of breath). No prior hx (history) or clinical signs of DVT (deep vein thrombosis) or PE (pulmonary embolism). No recent surgery or immobilization. No pulsatile abdominal mass or reported abdominal pain, unlikely ruptured AAA (abdominal aortic aneurysm). Patient denies tearing chest pain or back pain. Doubt aortic dissection. No cardiac murmur. Doubt Aortic stenosis. Even not associated with exertion to indicate HOCM (Hypertropic Obstructive Cardiomyopathy). Patient denies any palpitations, or chest pain. Doubt ACS (acute coronary syndrome) or dysrhythmia. No hx of CHF (congestive heart failure) or dyspnea. BP stable. EKG: NSR (normal sinus rhythm, no ischemic changes. Clinical Impression: 1. Dizziness 2. Hypertension 3. Generalized weakness I have discussed the results Dx (diagnosis) and Tx (treatment) plan with the patient. They expressed understanding and agree with the plan and were told to return to the ED with any worsening condition or concern. Pt seen in conjunction with attending physician, Dr. (DED Physician A), who participated in medical decision making."

Review of nursing documentation at 1551 revealed "Dr. (DED Physician A) at beside."

Review of MSE documentation by DED Physician A dated 09/04/2014 at 0846 revealed "Pt with generalized weakness, initially in left leg then progressing to bilateral legs and arms over the time span of only minutes. Not consistent with CVA (cerebral vascular accident) given bilateral nature of symptoms of arms and legs as this would require a massive ischemic insult. Labs unremarkable other than minimally elevated CK, consistent with pt's report of 'dancing' this morning. No indication for further emergent workup. Symptoms fully resolved and pt ambulating in ED with steady gait. She denies any weakness. Stable for discharge."

Review of MSE documentation by Resident Physician #2 dated 09/03/2014 at 1947 revealed "Pt care assumed from Dr. (Resident Physician #1) @ (at) 1600. Please refer to their note for complete history and physical. Briefly, pt is a 64 y.o. female with PMH of HTN presenting with 'heaviness' of her lower extremity; family members concerned for stroke given weakness which they were uncertain about. Upon arriving to the ED patient states her symptoms resolved and she was seen ambulating to the bathroom without difficulty around the ED. Current plan is as follows: -Follow up EKG, CXR, CK, CBC, BMP -Likely discharge given symptoms resolved, patient is ambulating, and patient is asking to go home -Close follow up with PCP (primary care physician). -Blood pressure control needs improvement at baseline." Review revealed "Labs Reviewed CBC - Abnormal; Notable for the following MCHC 32.5(*) [reference range 33.0 - 37.0 Grams/Deciliter] All other components within normal limits CK - Abnormal; Notable for the following CK 184(*) [reference range 50 - 160 Units/Liter] All other components within normal limits Comprehensive Metabolic Panel." Review of Disposition: revealed "-Unlikely to be TIA (transient ischemic attack) or stroke; however she should follow up with her PCP within a week for evaluation of these symptoms. Concerning her blood pressure has been running in the 180s SBP (systolic blood pressure); she has no end organ damage signs and the patient was instructed multiple times to return if she had any vision changes, acute numbness or weakness, severe sudden onset headache, or chest pain. Also emphasized close follow up with PCP. No acute cardiac or pulmonary findings. -Follow up with PCP for better blood pressure control. -Please return to the ED if these symptoms return or persist. ...Patient was seen in conjunction with Dr. (DED Physician B), who oversaw medical decision making."

Review of an Attending Supervisory Note dated 09/05/2014 at 2012 by DED Physician B revealed "I have personally seen and examined the patient, and discussed the plan of care with the resident. I have reviewed the nursing documentation on past medical history, family history, and social history. I have reviewed the documentation of the resident and agree."

Review of Medication Administration Record (MAR) documentation revealed the patient was administered Procardia (for blood pressure control) 10 mg by mouth at 1737 per physician's order.

Review of DED vital sign documentation revealed reassessment at:
1545: BP 177/82, P 83, R 16, O2 Sat 98%;
1615: BP 179/75, P 71, R 14, O2 Sat 99%;
1658: BP 180/76, P 76, R 16, O2 Sat 98%;
1715: BP 178/77, P 67, R 19, O2 Sat 98%;
1737: BP 188/71;
1745: BP 182/62, P 67, R 18, O2 Sat 100%;
1815: BP 184/73, P 69, R 16, O2 Sat 100%;
1830: BP 179/63, P 68, R 18, O2 Sat 99%; and
1845: BP 165/68, P 70, R 16, O2 Sat 98%.

Review of nursing documentation at 1918 revealed "Pt ambulate to d/c area without difficulty, VSS upon discharged."

Review of discharge instructions revealed "You have suffered an episode of weakness - given that it resolved quickly and the fact you have normal labs makes something like a stroke less likely -however you still should follow up with a doctor within 4 - 7 days. You may want to limit your activity for a day or so. -Please come back to the emergency room if you have symptoms Continuing or worsening -Follow up you're your doctor. -Your blood pressure is worrisome, please follow up with your primary care doctor as soon as possible and state your blood pressures have been in the 180s systolic. -Come back to the ED if you experience severe headache, vision changes, chest pain, or one sided weakness/numbness." Review revealed the patient was given written instructions for chronic hypertension.

Hospital B, closed DED record review on 02/12/2015 revealed Patient #22 presented to the DED on 09/04/2014 and at 1037. Review of MSE documentation by DED Physician C revealed a chief complaint of Fatigue. Review revealed "HPI Comments: This is a 64-year-old African-American female with a history of schizoaffective disorder hypertension who now presents with increasing left-sided weakness left face weakness left arm weakness. This patient was seen apparently yesterday at an outside hospital with a nonspecific complaint of weakness and heaviness apparently no definitive findings were recorded at that time the patient was deemed stable for outpatient management. Her symptoms do seem to have begun yesterday there with left-sided weakness which she describes as a heaviness and fatigue but does seem to have been much worse on the last no more florid and obviously it is a left-sided deficit. The daughter first noticed something was missed this morning when she noted mom said face is corrected [sic] (crooked) this morning while putting on her makeup. That was approximately between 8:30 and 9:30 this morning but does seem like the deficit probably started at 2 PM or so yesterday." Review revealed "Review of Systems ...Neurological: Negative for dizziness, facial asymmetry and headaches. ..." Review revealed ED triage vitals were BP: 165/67, P 77, R 21, O2Sat 98%, and T 97.9 degrees F. Review of Physical Exam revealed "...Eyes: ...Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. ...Neurological: She is alert and oriented to person, place, and time. She has normal reflexes. A cranial nerve deficit and sensory deficit is present. She exhibits abnormal muscle tone. ...Neurologically she has a pronator drift on the left she has 3+ power in grip in the left wrist in flexion and extension of the left arm she is approximately 3+ power in the left leg flexion at the hip and extension at the knee she has left facial droop. Babinski sign is positive on the left. ..." Review revealed a CT (computed tomography) of the Brain Head without contrast was performed with an impression of "No acute intracranial abnormality identified." Review revealed an MRI (magnetic resonance imaging) of the Brain/ Head without contrast was performed with an impression of "1. Acute infarct in portions of the right corpus striatum (caudate and putamen), consistent with lenticulostriate branch occlusion. ..." Review revealed an ED Clinical Impression of Cerebral Vascular Accident and Left-sided muscle weakness. The patient was admitted to an inpatient unit and discharged 09/06/2014.

In brief, Hospital A's DED physicians failed to provide an appropriate MSE within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an EMC existed for Patient #22. Subsequently, Patient #22 was discharged from Hospital A's DED on 09/03/2014 at 1918 and presented to Hospital B's DED on 09/04/2014 at 1037 (15 hours 19 minutes later) and was diagnosed with a Cerebral Vascular Accident (CVA) and left sided weakness; was admitted to an inpatient unit and discharged on 09/06/2014 (2 days later).

Based on hospital policy review and medical record reviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 13 sampled patients who presented to the hospital's DED with an EMC and was discharged. (Patient #22)

The findings include:

Review on 02/11/2015 of current hospital policy "EMTALA (The Emergency Medical Treatment and Active Labor Act: Screening, Stabilization, and Transfer of Individuals with Emergency Medical Conditions)" revised 06/2014, revealed "I. General Policy Statement... A. It is the policy of (Hospital A) to provide appropriate Medical Screening Examinations to individuals to determine wither [sic] emergency medical conditions exist and receives and refers appropriate patient transfers. 1. To determine whether an emergency medical condition exists by providing a Medical Screening Examination by a physician or other Qualified Medical Person to any individual described in Section I.B. to determine if the individual has an Emergency Medical Condition, whether or not he or she is eligible for insurance benefits and regardless of his or her ability to pay; and 2. It is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of (Hospital A), or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. ...B. These Policies and Procedures apply to: 1. all individuals....who present at any Dedicated Emergency Department of (Hospital A), as defined in Section II - Definitions, and request examination or treatment for a medical condition, or has such a request made on his or her behalf. ...a) Scope: All (Hospital A) employees, faculty and staff are responsible for complying with this policy. ...II. Definitions: For purposes of this Policy, the following terms and definitions apply: ...d) 'Comes to the Emergency Department' means, with respect to an individual who is not a patient, the individual either: 1. has presented at a Medical Center's Dedicated Emergency Department and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...g) 'Emergency Medical Condition' means: 1. a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in either: a. placing the health of the individual....in serous jeopardy; b. serious impairment to bodily functions; or c. serous dysfunction of any bodily organ or part; ...o) 'To Stabilize' means, with respect to an Emergency Medical Condition: 1. to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility; ...p) 'Stable for Discharge' means: 1. the physician has determined, within reasonable clinical confidence, that the patient has reached the point where his/her continued medical treatment, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instructions; ...s) 'Within the Capability of Medical Center' means those services which (Hospital A) is required to have as a condition of its licensure, as well as (Hospital A) ancillary services routinely available to the emergency department. III. Policy Guidelines ...C. Individuals Who Have an Emergency Medical Condition 1. When the emergency department physician or Qualified Medical Person determines that the individual has an Emergency Medical Condition, (Hospital A); a. within the capability of the staff and facilities available at (Hospital A), stabilizes the individual to the point where the individual is either 'stable for discharge' or 'stable for transfer,' as defined in Section II.P and Section II. Q...; ...c. after stabilizing the individual, admits him or her to (Hospital A) for further treatment. ..."

Hospital A, closed DED record review on 02/11/2015 for Patient #22 revealed a 64 year old female who presented via ambulance to the DED on 09/03/2014 at 1512. Review revealed the patient was triaged by a Registered Nurse at 1519. Review of triage documentation revealed a chief complaint of Extremity Weakness, review revealed "Pt (patient) c/o (complains of) left leg heaviness and weakness that began today. Denies Pain." Review revealed initial vital signs (VS) were assessed as temperature (T) 99.2 degrees Fahrenheit (F); Pulse (P) 90; Respirations (R) 16; blood pressure (BP) 172/72; and Oxygen Saturation (SpO2) 99% on room air (RA). Review revealed an EKG (electrocardiogram) was performed at 1516. Review revealed "Sinus rhythm with short PR." Review of Past Medical History (PMH) revealed Schizoaffective Disorder, unspecified condition, Essential Hypertension (HTN), Pure hypercholesterolemia, Dizziness, and Unspecified transient cerebral ischemia et al. Review of home medications revealed Procardia-XL 30 mg (milligrams) take 1 tablet by mouth daily, Aspirin 81 mg take 1 tablet by mouth daily, and Fluphenazine Decanote 25 mg/ml injection. Review revealed the patient was assigned an Acuity Level - Urgent.

Review of MSE documentation by Resident Physician #1 dated 09/03/2014 at 1737 revealed a chief complaint of "Extremity Weakness." Review of History of Present Illness (HPI) revealed "Ms. (Patient #22 name) is a 64 y.o (year old) female with schizoaffective disorder, HTN, HLD (hyperlipidemia), and unspecified transient cerebral ischemia who presents to the ED for leg heaviness and weakness. Patient had been dancing at church this morning and came home to do laundry. Patient noticed left leg heaviness at 2pm and progress to b/l (bilateral) leg heaviness. Noticed full body weakness and sat down on bed. Did not feel dizzy or lightheaded. Denies heart palpitations, blurred vision, nausea, vomiting, or diarrhea. Currently she is completely asymptomatic and denies any other complaints." Review revealed a Past Medical History (PMH) of Schizoaffective disorder, unspecified condition; Essential hypertension, benign; Pure hypercholesterolemia; Dizziness; Unspecified transient cerebral ischemia, et al. Review of Review of Systems revealed "Constitutional: Negative for fever. HENT (Head, Eyes, Nose, Throat): Negative for congestion. Respiratory: Negative for cough. Gastrointestinal: Negative for nausea, vomiting and diarrhea. Neurological: Negative for weakness. All other systems reviewed and are negative." Review of Physical Exam revealed "Constitutional: She appears well-developed. HENT: Head: Normocephalic. Eyes: Conjunctivae are normal. Neck: Normal range of motion. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: Effort normal. Abdominal: Soft. Neurological: She is alert. Skin: Skin is warm and dry. Psychiatric: She has a normal mood and affect." Review of ED Course revealed a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Creatine Kinase (CK), and Electrocardiogram was performed. Review of Medical Decision Making (MDM) revealed "Pt care was handed off to Dr. (Resident Physician #2) at 1600. Complete history and physical and current plan have been communicated. Please refer to their note for the remainder of ED care. Patient likely having psychosomatic complaints of heaviness in legs. Patient denies headache prior to or currently. Neuro exam non focal. Doubt SAH (subarachnoid hemorrhage) or ICH (intracranial hemorrhage). No diplopia, dysarthria, ataxia, or vertigo prior to or after the event, doubt posterior circulation stroke. No postictal period or witnessed tonic clonic movements to suggest seizure. Patient denies any chest pain, dyspnea, or SOB (shortness of breath). No prior hx (history) or clinical signs of DVT (deep vein thrombosis) or PE (pulmonary embolism). No recent surgery or immobilization. No pulsatile abdominal mass or reported abdominal pain, unlikely ruptured AAA (abdominal aortic aneurysm). Patient denies tearing chest pain or back pain. Doubt aortic dissection. No cardiac murmur. Doubt Aortic stenosis. Even not associated with exertion to indicate HOCM (Hypertropic Obstructive Cardiomyopathy). Patient denies any palpitations, or chest pain. Doubt ACS (acute coronary syndrome) or dysrhythmia. No hx of CHF (congestive heart failure) or dyspnea. BP stable. EKG: NSR (normal sinus rhythm, no ischemic changes. Clinical Impression: 1. Dizziness 2. Hypertension 3. Generalized weakness I have discussed the results Dx (diagnosis) and Tx (treatment) plan with the patient. They expressed understanding and agree with the plan and were told to return to the ED with any worsening condition or concern. Pt seen in conjunction with attending physician, Dr. (DED Physician A), who participated in medical decision making."

Review of nursing documentation at 1551 revealed "Dr. (DED Physician A) at beside."

Review of MSE documentation by DED Physician A dated 09/04/2014 at 0846 revealed "Pt with generalized weakness, initially in left leg then progressing to bilateral legs and arms over the time span of only minutes. Not consistent with CVA (cerebral vascular accident) given bilateral nature of symptoms of arms and legs as this would require a massive ischemic insult. Labs unremarkable other than minimally elevated CK, consistent with pt's report of 'dancing' this morning. No indication for further emergent workup. Symptoms fully resolved and pt ambulating in ED with steady gait. She denies any weakness. Stable for discharge."

Review of MSE documentation by Resident Physician #2 dated 09/03/2014 at 1947 revealed "Pt care assumed from Dr. (Resident Physician #1) @ (at) 1600. Please refer to their note for complete history and physical. Briefly, pt is a 64 y.o. female with PMH of HTN presenting with 'heaviness' of her lower extremity; family members concerned for stroke given weakness which they were uncertain about. Upon arriving to the ED patient states her symptoms resolved and she was seen ambulating to the bathroom without difficulty around the ED. Current plan is as follows: -Follow up EKG, CXR, CK, CBC, BMP -Likely discharge given symptoms resolved, patient is ambulating, and patient is asking to go home -Close follow up with PCP (primary care physician). -Blood pressure control needs improvement at baseline." Review revealed "Labs Reviewed CBC - Abnormal; Notable for the following MCHC 32.5(*) [reference range 33.0 - 37.0 Grams/Deciliter] All other components within normal limits CK - Abnormal; Notable for the following CK 184(*) [reference range 50 - 160 Units/Liter] All other components within normal limits Comprehensive Metabolic Panel." Review of Disposition: revealed "-Unlikely to be TIA (transient ischemic attack) or stroke; however she should follow up with her PCP within a week for evaluation of these symptoms. Concerning her blood pressure has been running in the 180s SBP (systolic blood pressure); she has no end organ damage signs and the patient was instructed multiple times to return if she had any vision changes, acute numbness or weakness, severe sudden onset headache, or chest pain. Also emphasized close follow up with PCP. No acute cardiac or pulmonary findings. -Follow up with PCP for better blood pressure control. -Please return to the ED if these symptoms return or persist. ...Patient was seen in conjunction with Dr. (DED Physician B), who oversaw medical decision making."

Review of an Attending Supervisory Note dated 09/05/2014 at 2012 by DED Physician B revealed "I have personally seen and examined the patient, and discussed the plan of care with the resident. I have reviewed the nursing documentation on past medical history, family history, and social history. I have reviewed the documentation of the resident and agree."

Review of Medication Administration Record (MAR) documentation revealed the patient was administered Procardia (for blood pressure control) 10 mg by mouth at 1737 per physician's order.

Review of DED vital sign documentation revealed reassessment at:
1545: BP 177/82, P 83, R 16, O2 Sat 98%;
1615: BP 179/75, P 71, R 14, O2 Sat 99%;
1658: BP 180/76, P 76, R 16, O2 Sat 98%;
1715: BP 178/77, P 67, R 19, O2 Sat 98%;
1737: BP 188/71;
1745: BP 182/62, P 67, R 18, O2 Sat 100%;
1815: BP 184/73, P 69, R 16, O2 Sat 100%;
1830: BP 179/63, P 68, R 18, O2 Sat 99%; and
1845: BP 165/68, P 70, R 16, O2 Sat 98%.

Review of nursing documentation at 1918 revealed "Pt ambulate to d/c area without difficulty, VSS upon discharged."

Review of discharge instructions revealed "You have suffered an episode of weakness - given that it resolved quickly and the fact you have normal labs makes something like a stroke less likely -however you still should follow up with a doctor within 4 - 7 days. You may want to limit your activity for a day or so. -Please come back to the emergency room if you have symptoms Continuing or worsening -Follow up you're your doctor. -Your blood pressure is worrisome, please follow up with your primary care doctor as soon as possible and state your blood pressures have been in the 180s systolic. -Come back to the ED if you experience severe headache, vision changes, chest pain, or one sided weakness/numbness." Review revealed the patient was given written instructions for chronic hypertension.

Hospital B, closed DED record review on 02/12/2015 revealed Patient #22 presented to the DED on 09/04/2014 and at 1037. Review of MSE documentation by DED Physician C revealed a chief complaint of Fatigue. Review revealed "HPI Comments: This is a 64-year-old African-American female with a history of schizoaffective disorder hypertension who now presents with increasing left-sided weakness left face weakness left arm weakness. This patient was seen apparently yesterday at an outside hospital with a nonspecific complaint of weakness and heaviness apparently no definitive findings were recorded at that time the patient was deemed stable for outpatient management. Her symptoms do seem to have begun yesterday there with left-sided weakness which she describes as a heaviness and fatigue but does seem to have been much worse on the last no more florid and obviously it is a left-sided deficit. The daughter first noticed something was missed this morning when she noted mom said face is corrected [sic] (crooked) this morning while putting on her makeup. That was approximately between 8:30 and 9:30 this morning but does seem like the deficit probably started at 2 PM or so yesterday." Review revealed "Review of Systems ...Neurological: Negative for dizziness, facial asymmetry and headaches. ..." Review revealed ED triage vitals were BP: 165/67, P 77, R 21, O2Sat 98%, and T 97.9 degrees F. Review of Physical Exam revealed "...Eyes: ...Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. ...Neurological: She is alert and oriented to person, place, and time. She has normal reflexes. A cranial nerve deficit and sensory deficit is present. She exhibits abnormal muscle tone. ...Neurologically she has a pronator drift on the left she has 3+ power in grip in the left wrist in flexion and extension of the left arm she is approximately 3+ power in the left leg flexion at the hip and extension at the knee she has left facial droop. Babinski sign is positive on the left. ..." Review revealed a CT (computed tomography) of the Brain Head without contrast was performed with an impression of "No acute intracranial abnormality identified." Review revealed an MRI (magnetic resonance imaging) of the Brain/ Head without contrast was performed with an impression of "1. Acute infarct in portions of the right corpus striatum (caudate and putamen), consistent with lenticulostriate branch occlusion. ..." Review revealed an ED Clinical Impression of Cerebral Vascular Accident and Left-sided muscle weakness. The patient was admitted to an inpatient unit and discharged 09/06/2014.

In brief, Hospital A's DED physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for Patient #22. Subsequently, Patient #22 was discharged from Hospital A's DED on 09/03/2014 at 1918 and presented to Hospital B's DED on 09/04/2014 at 1037 (15 hours 19 minutes later) and was diagnosed with a Cerebral Vascular Accident (CVA) and left sided weakness; was admitted to an inpatient unit and discharged on 09/06/2014 (2 days later).