HospitalInspections.org

Based on review of hospital policies and procedures, hospital documents, medical records and staff interviews, it was determined the Hospital failed to perform a proper triage and medical screening examination for one (1) patient (Patient #1) that presented to the Emergency Department complaining of unsteadiness and confusion, which poses a potential risk of the patient developing unwarranted complications related to exhibited symptoms when a medical screening examination is not performed expeditiously.

Findings include:

Patient #1 presented to the hospital's Emergency Department (ED) on 02/27/2023 at 1309 with confusion, unsteady gait and headache. Patient #1 was triaged at 1337 with an Emergency Severity Index (ESI) of 2 and was placed in the ED lobby after triage. Patient #1 was roomed in the ED at 1448 and a medical screening examination (MSE) was performed and a stroke alert was initiated. Patient #1 underwent a CT scan of the head which revealed Patient #1 was experiencing a stroke. Patient #1 medical condition continued to decline and Patient #1 was intubated and placed on a ventilator at 1630. Patient #1 was subsequently transferred to Hospital #2 [Banner Desert Medical Center] for Neurological Interventional Radiology. Patient #1 died at Hospital #2 on 03/01/2023.

Hospital policy titled, "Emergency Department Patient Care", revealed: "...An emergency exists if all of the following circumstances are met: The person is in immediate need of medical attention; The person has not refused this emergency medical treatment at a time when he/she had Decision-Making Capacity; An attempt to secure expressed consent would result in delay of treatment and; Delay in treatment would increase the risk to the person's life or health...Triage assessment: Completed by a RN, Paramedic or QMP...An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 1= Requires immediate life-saving interventions; ESI 2= High risk situation or confused, lethargic/disoriented or severe pain distress; ESI 3= Two or more resources may be needed; ESI 4= One resource may be needed; ESI 5= No resources needed...ED triage documentation may include, but is not limited to: Chief complaint, vital signs, pain, and oxygenation; Mode of arrival and mechanism of injury; Triage assessment and ESI scoring; Infectious Disease Screening; Suicide Screening...Medical Screening Exam: A medical screening exam (MSE) is completed by an Emergency Physician or QMP...Assessment/ Reassessment: Comprehensive Assessment performed by the RN....Occurs according to the patient's clinical presentation or any significant clinical event with the minimum requirements as follows: ESI 1= Continuous observation and monitoring, with documented reassessment at a minimum of every 1 hour until hemodynamically stable, then minimally every 2 hours or per admitting unit guidelines of care. ESI 2= Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care....Reassessments may include, but are not limited to: patient's current condition/status, Pain, Response to interventions...General Nursing Care: Patients arriving from all portals of entry into the ED will receive a baseline assessment of their chief complaint by a registered nurse, physician or designee...An ESI score will be assigned based upon acuity and resources needed; Patients assigned ESI level 1&2 to be given placement priority...."

Hospital policy titled, " EMTALA-Medical Screening Examination and Stabilization Treatment " , revealed: "...Banner Health provides care for individuals presenting to its hospitals (and Dedicated Emergency Departments, as defined below) with emergency medical conditions without discrimination and regardless of their payor status or eligibility for financial assistance...Definitions:...Emergency Medical Condition or EMC:1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a Psychiatric Emergency) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part...Policy:...A. Medical Screening Examination ( " MSE " ). 1. An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance or behavior would cause a prudent layperson observer to believe that such individuals need emergency examination or treatment...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. An MSE will be conducted to determine whether the Patient has an EMC. The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions. The MSE is an ongoing process requiring continuing monitoring based upon the Patient ' s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred...."

Hospital document titled, "Banner Health Acute Ischemic Stroke/TIA Clincal Practice", revealed: "...All adult patients who present to the Emergency Department (ED) with acute neurologic symptoms consistent with stroke will undergo emergent evaluation and treatment, including high acuity assignment in triage, a standard focused history, a standard focused neurological exam, expedited diagnostics including continuous cardiac monitoring and a stat brain CT without contrast, and prompt control of blood pressure and blood glucose as indicated. All adult patients who present to the Emergency Department (ED) with symptoms of an acute ischemic stroke will be evaluated as candidates for treatment with intravenous (IV) thrombolysis and/or endovascular therapy including mechanical thrombectomy if they meet specific criteria for acute intervention as outlined below...Prompt identification of patients with an acute ischemic stroke facilitates effective delivery of time-sensitive therapies, including IV thrombolysis and mechanical thromobectomy, which must be delivered within a narrow therapeutic window...The goal of the rapid assessment of all acute stroke-like symptoms is to complete the initial evaluation and initiate definitive management as quickly as possible (at a maximum within 60 minutes) of patient arrival in the ED...Triage: The narrow therapeutic window available for appropriate interventions in acute ischemic stroke requires an efficient and rapid pathway for evaluation, diagnosis, and treatment. patients with stroke may clinically decline rapidly during the acute phase. All patients presenting with suspected stroke, and new symptoms of less than 24 hours duration, will be defined to be experiencing "acute stroke" and triaged as at least an "Emergency Severity Index (ESI) level 2", or "emergent" acuity, reflecting the critical, time-sensitive nature of making the correct diagnosis...An acute stroke should be suspected in all patients with a sudden unexplained neurological change...This includes (but is not limited to): focal weakness or numbness of the extremities or face, particularly when unilateral; speech language changes; changes in vision, either monocular or binocular; coordination deficits; sudden unexplained headache, particularly if associated with altered level of consciousness...For patients unable to provide the time of onset of symptoms, or who awoke with symptoms, the time of onset is defined as the time when the patient was last known to be awake and without new signs or symptoms (LKAW= last known awake and well)...goal Evaluation and Treatment Times: Door to Physician <10 min; Door to Stroke Code< 15 min; Door to Stroke Team <20 min; Door to Non-contrast CT (stroke protocol)< 20 min; Door to labs/CT Read< 45 min; Door to Needle (Alteplase) ideally< 30 min...."

Hospital document titled, "Stroke Alert Worksheet ", revealed: "...Patient Arrival Time:_______...Last Time the Patient was Baseline Normal:_____...BEFAST Symptoms: Balance/Gar Change; Vision Changes; Facial Droop; Arm Weakness/Numbness; Leg Weakness/Numbness; Slurred Speech/Language...Other Symptom History:_________; Assess for Large Vessel Occlusion: Unilateral Arm Weakness/Paralysis; PLUS (1) from below: Vision; Aphasia; Neglect....If NIHSS is .6 OR VAN positive; consider CTA/CTP after tPA decision...."

Patient #1 Triage Note dated 02/27/2023 at 1342 revealed Patient #1 registered at 1309 and was triaged at 1337. Patient #1 chief complaint was documented as "...pt{sic} qith acute confusion/unsteadiness starting at 1100 today per [wife] wth unsteadiness, has had sinus headache for the past several days, FAST (facial drooping, arm weakness, speech difficulties, and time) neg, VAN (vision, aphasia, neglect) neg...Blood pressure 151/97...Tracking Acuity (ESI) 2...."

Review of the ED Patient Summary Activity in the electronic medical record revealed Patient #1 was triaged at 1337 and placed in an ED room at 1449.

Patient #1 ED Provider note dated 02/27/2023 revealed: "...provider patient care initiated 02/27/2023 1449...The patient presents with weakness, altered speech, altered gait, and confusion course of symptoms is constant. The character of symptoms is weakness and off-balance. The degree at onset was moderate. The degree at present is severe. Associated symptoms: vomiting...HPI is limited due to patient's clinical condition and primarily dictated by patient's [wife]. patient is a [76 y/o male] with a history of CABG presenting to the emergency department via private vehicle complaining of worsening confusion/unsteadiness onset at 1100 this morning. Per patient's [wife], patient was going about [his] daily routine as usual this morning when [he] began to experience confusion. [His] confusion has progressively increased. Patient's [wife] adds that when they arrived at the emergency department, [he] was able to speak but has been quickly deteriorating. Patient then began vomiting. I saw patient as [he] was being wheeled back to the room and immediately evaluated [him] on arrival to [his] room. Patient is no longer verbal and is vomiting...ED course: Patient presented to the emergency department for evaluation of altered mental status. Patient's symptoms have worsened acutely over approximately the past hour. Patient was evaluated immediately upon arrival to a room with concern for CVA. Unfortunately, patient is out of the window for tPA administration. This was discussed with [his wife] who understands. CTA with perfusion was also immediately performed and revealed evidence of bilateral vertebral artery occlusion with basilar artery stenosis/thrombosis. Neuro interventional radiology was immediately contacted and agrees with transfer for possible neuro intervention. Patient was intubated for airway protection given that [he] was having some sonorous respirations. Patient has been provided aspirin. Unfortunately, prognosis is extremely guarded at this time...."

Further review of Patient #1 medical record revealed a stroke alert was initiated at 1452 with stroke team arrival at 1458.

Patient #1 was transferred to Hospital #2 on 02/27/2023 at 1623 as a direct admit to the intensive care unit.

A total of 19 ED medical records were randomly selected for review included patients who were transferred, admitted, or left before Medical Screening Examinations. Thirteen (13) of the medical records reviewed were for patients with chief complaints of altered mental status. weakness or potential stroke. All of the 13 patients received a Medical Screening Examination within thirty (30) minutes of arrival to the ED. There was no documentation that there were any delays in assessments and/or treatments based on each of the 19 patient's ability to pay for medical services.

Employee #8 confirmed on 05/09/2023 that Patient #1 was not triaged appropriately and should have had a stroke alert initiated at time of triage. Employee #8 confirmed that Patient #1 should have been evaluated using BEFAST (balance, eyes,face, arms, speech, and time) instead of FAST. Employee #8 confirmed that patients with an ESI of 2 have a higher priority than ESI 3, and ESI 5 patients.

Employee #9 confirmed on 05/09/2023 that Patient #1 should have had a stroke alert called in triage based on the unsteadiness Patient #1 was experiencing. Employee #9 confirmed that Patient #1 did not receive tPA because the window for administration had elapsed. Employee #9 confirmed the timeframe to give tPA is 3 hours from the initial onset of symptoms. Employee #9 confirmed that the patient was in the ED within the 3 hours window but was not seen by a provider until the 3 hour window had elapsed.