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Based on hospital documents, policy review, and medical record review, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #4) sampled patients.

The findings included:

1. Review of the hospital's document titled, "Medical Staff Bylaws" dated 4/20/2023 revealed, "...The purposes of the Medical Staff are...to provide a mechanism to ensure that all patients admitted to or treated in any of the facilities or services of the Hospital shall receive a uniform level of appropriate quality care, treatment and services..."

Review of the hospital's document titled, "Medical Staff Rules and Regulations" dated April 20, 2023, revealed, "...Emergency Medical Screening...Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition..."

2. Review of the hospital's policy titled, "Neurological Assessment" dated 4/11/2023 revealed, "...Purpose: Determine the patient's neurological status. Establish a baseline for determining and evaluating changes in the neurological status...Neurological assessments will be patient specific and/or per physician's order...The following neurological examination is not the most extensive neurologic check possible, but one examining the five critical areas: (1) level of consciousness (2) pupillary activity, (3) motor function, (4) sensory function, and (5) vital signs. It is the responsibility of the nurse to be consistent and use best judgments as to how in depth or detailed the neurological assessment for each patient is performed. When in doubt as to how frequent this assessment must be done remember the slightest decline in neuro function must be associated with more frequent neurological checks..."

3. Medical record review revealed Patient #4 was a 49-year-old nursing home resident with a history of seizures and Schizophrenia. Patient #4 was transported via ambulance from Skilled Nursing Facility (SNF) #1 to Hospital #1's ED on 5/19/2024 with a chief complaint of seizure. The Pre-Arrival summary report received from SNF #1 revealed the patient had difficulty following directions, walked with a shuffling gait, and was able to talk when she wanted to. The summary further revealed Patient #4 had been walking, and she had a seizure and fell resulting in a knot (hematoma) on the back of her head. The summary also revealed the patient's left pupil was "less reactive than right."

A triage assessment was completed on 5/19/2024 at 5:23 PM and showed Patient #4 had a seizure and fell out of bed against the wall. The full nursing assessment was also completed at 5:23 PM and revealed Patient #4 had a seizure while she was in the bed, and she fell and hit her head on the wall. Patient #4 was noted to have a hematoma with no bleeding and was "non verbal" and "alert."

The MSE was initiated by ED Provider #1 on 5/19/2024 at 5:49 PM and revealed the patient had a seizure and fell out of bed and hit her head against the wall while at SNF #1. The patient was noted to have a hematoma to the occipital scalp region (back of the head). The patient was noted be "alert," her musculoskeletal status showed, "No swelling, no deformity" and her neurological status was documented as "Alert, cooperative." The patient was diagnosed with "Breakthrough seizure" and "Scalp Hematoma" and discharged back to the SNF in "stable" condition via ambulance. ED Provider #1 documented, "Patient is at baseline functional neurologic state at this time."

There was no documentation ED Provider #1, Registered Nurse (RN) #2 or RN #3 were aware Patient #4 could ambulate and was able to talk when she wanted to or that Patient #4 had been ambulating when she had a seizure and fell backward striking her head on the wall as documented in the Pre-Arrival summary. There was no documentation Patient #4's motor strength and coordination were re-assessed prior to her discharge from Hospital #1's ED on 5/19/2024 at 7:09 PM.

Upon Patient #4's return to SNF #1, staff noted Patient #4 was lethargic. SNF staff members monitored the patient and noted the patient was no longer talking or moving her extremities. The patient was transported back to the Hospital #1 ED via ambulance on 5/20/2024.

After arrival to the Hospital #1 ED, a triage assessment was completed on 5/20/2023 at 2:45 AM and showed the patient was not walking or responding to painful stimuli.

The MSE was initiated by ED Provider #2 on 5/20/2024 at 3:05 AM and revealed the patient had been seen earlier following a seizure and had fallen out of bed hitting the back of her head. The head CT was negative, and the patient was given IV fluids and Keppra and sent back to the SNF. The patient was noted to be looking around but not moving her arms or legs and was brought back to the ED for evaluation. ED Provider #2 assessed the patient and indicated Patient #4 was opening her eyes spontaneously, her pupils were equal, round and reactive, and Patient #4 "...pulls back left leg with babinski flexion test [a test for central nervous system problems], no change in movement with pin prick tool..." The ED Provider ordered a repeat CT of the Head as well as a CT of the Cervical (C) Spine. ED Provider #2 also called SNF #1 and obtained a report regarding the mechanism of injury as well as the patient's baseline level of functioning. The head CT showed no intracranial abnormality. The cervical spine CT showed an "acute C2 fracture involving the posterior elements bilaterally..."

A cervical collar (device used to support the spinal cord and head) was applied, neurosurgery services were consulted, and neurosurgery recommended Patient #4 be transferred to Hospital #2 with a Level 1 Trauma unit for further treatment.

Patient #4 was transferred to Hospital #2 via ambulance in guarded condition on 5/20/2024 at 6:20 AM.

Refer to A2406.

Based on hospital documents, policy review, medical record review, nursing home documents, and interviews, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for one (1) of 20 (Patient #4) sampled patients.

The findings included:

1. Review of the hospital's document titled, "Medical Staff Bylaws" dated 4/20/2023 revealed, "...'Medical Staff Bylaws' means the Bylaws of the Medical Staff and the accompanying Rules & Regulations... and such other policies as may be adopted by Medical Staff subject to the approval of the Board... The purposes of the Medical Staff are...to provide a mechanism to ensure that all patients admitted to or treated in any of the facilities or services of the Hospital shall receive a uniform level of appropriate quality care, treatment and services..."

Review of the hospital's document titled, "Medical Staff Rules and Regulations" dated April 20, 2023, revealed, "...Emergency Medical Screening, Treatment, Transfer... Policy... Screening... Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an 'emergency medical condition' is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child... All patients shall be examined by qualified medical personnel... Services available to Emergency Department patients shall include all ancillary services routinely available to the Emergency Department... Stabilization... Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge... A patient is Stable for Discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or when the patient requires no further treatment and the treatment physician has provided written documentation of his/her findings... A patient is Stable for Transfer if the treatment physician has determined, within reasonable clinical confidence, that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition..."

2. Review of the hospital's policy titled, "Neurological Assessment" dated 4/11/2023 revealed, "...Purpose: Determine the patient's neurological status. Establish a baseline for determining and evaluating changes in the neurological status...Neurological assessments will be patient specific and/or per physician's order... The following neurological examination is not the most extensive neurologic check possible, but one examining the five critical areas: (1) level of consciousness (2) pupillary activity, (3) motor function, (4) sensory function, and (5) vital signs. It is the responsibility of the nurse to be consistent and use best judgments as to how in depth or detailed the neurological assessment for each patient is performed. When in doubt as to how frequent this assessment must be done remember the slightest decline in neuro function must be associated with more frequent neurological checks...Use the following information as a guideline in determining the level of consciousness: - Alert - Responds immediately, fully and appropriately to visual, auditory, or tactile stimulation... Lethargic - Drowsy, sleeps a lot, but is easily aroused and then responds appropriately to visual, auditory, or tactile stimulation... Evaluate the patient's pupils for size, shape, equality, and reactivity to light... Evaluate the patient's motor function closely observing muscle strength, muscle tone, posture, muscle coordination, reflexes, and abnormal movements... Observe patient's spontaneous movements... Have the patient squeeze our fingers with both hand simultaneously. Compare strength of each to the other... With patient lying down, have the patient pull simultaneously with toes of both feet against your hands comparing strength of each... Observe motor movement of patients unable to follow commands by eliciting movement with tactile stimulation in graded intensity... Note: Be alert for abnormal movement when you assess motor function... Assess 3 of the most important reflexes... Test patient's blink reflexes by having him/her look up or hold his/her eyelid open and approach the eye unexpectedly from the side or brush the eyelashes. a) If blink reflex is intact, his/her eye will close immediately. b) If it is not intact, the patient will need special eye care... Test gag and swallow reflex... Test the plantar reflex by stroking the lateral aspect of the sole of the patient's foot. a) The normal response is flexion of the toes. b) The Babinski response is abnormal. The great toe will dorsiflex and the other toes fan..."

3. Review of Patient #4's Annual Minimum Data Set (MDS) assessment from Skilled Nursing Facility (SNF) #1 completed on 10/1/2023 revealed Patient #4 was a 49 year-old female severely cognitively impaired who exhibited no behaviors and was able to walk independently.

Review of an Incident report for Patient #4 from SNF #1 dated 5/19/2024 at 3:45 PM revealed Patient #4 was "...ambulating in hallway and had a seizure and fell striking head on the wall. Large hematoma [localized bleeding outside of blood vessels] noted to top left head. Left pupil sluggish at time of fall. additional neuro [neurological] checks difficult to obtain due to post- ictal [the middle stage of a seizure] status, Speech clear. Assessment done with no other injuries noted. Resident Description: I fell and it hurt my head... Vital signs obtained, neuro checks obtained, secured residents safety due to seizure activity, grimacing noted, skin warm and dry, no skin discoloration, resp [respirations] even non labored, MD [Medical Doctor] notified, orders obtained to call 911 to send to ER [Emergency Room] for further eval [evaluation] and treat... Mental Status Oriented to Person... Predisposing Physiological Factors Confused...Gait Imbalance Impaired Memory..."

Review of the SBAR [stands for Situation, Background, Assessment and Recommendation; is a structured communication framework that can help teams share information about the condition of the patient] Communication Form for Patient #4 from SNF #1 dated 5/19/2024 revealed, "...Falls, Seizure... Mental Status Evaluation (compared to baseline; check all that you observe)... Decreased level of consciousness (sleepy, lethargic)... Sudden change in level of consciousness or responsiveness... Functional Status Evaluation... Fall... Associated with no or minor injury... Hematoma to left back/side of head at crown area... Seizure... Summarize your observations and evaluation: Ambulating independently in hall. Had a seizure and fell back & [and] hit head on wall causing hematoma to back/left side of head. Speech clear. Able to stand and pivot to wc [wheelchair], then back again to bed. Sent to ER... Reported to Primary Care Clinician...15:55 [3:55 PM]..."

Review of the Nursing Home to Hospital Transfer Form dated 5/19/2024 revealed, "...Reason for transfer Fall... Usual Mental Status: Alert, disoriented, but can follow simple instructions... Usual Functional Status: Ambulates independently... SBAR Acute Change in Condition Note included... Report Called in To [RN #1]... 5/19/2024 Time... 4:15 PM... Hx [history] seizures and was ambulating in hallway and it was observed by staff and residents that she had a seizure that caused her to fall backward hitting head on the wall causing hematoma to left side/back of head in crown area. Seizure subsided and she was able to say she fell and it hurt. Assessed with no other injuries. Was able to move all extremities as before fall. Assisted to sitting position then a standing position and she pivoted to wc [wheel chair] with normal shuffled gait. Once order was received to transfer to ER [patient] was assisted to bed. She stood from locked wc with assist and pivoted to bed. Police in facility awaiting EMS [Emergency Medical Services] arrival and was speaking to her and shook her hand. Report called to hospital and left safely secured on gurney accompanied by EMS..."

Review of the 911 call log dated 5/19/2024 at 4:18 PM revealed, SNF #1 called 911 regarding Patient #4. The log showed, "...Primary Incident Code... Fall/Back Injury... Did have a seizure but thats normal... Fell and hit her head and has a pupal [pupil] thats not dilating correctly... Is acting normal and breathing fine... Is he/she alert and able to talk... Yes... What exactly happened... Fall..."

Review of an Incident Note from SNF #1 dated 5/19/2024 at 4:30 PM revealed Patient #4 was "Up ad lib [as desired] ambulating in hallway and had a seizure and fell striking head on wall. Large hematoma noted to top left head. Left pupil sluggish at time of fall. Grips equal for her. Speech clear. Assessment done with no other injuries noted. Assisted up into wc and transferred into bed. Notified NP [Nurse Practitioner] with new order to transfer to ER for eval [evaluation] and tx [treatment]... report called to [RN #1] at [Hospital #1]..."

4. Review of the EMS report from EMS Service #1 dated 5/19/2024 revealed the ambulance unit was dispatched to SNF #1 at 4:21 PM and was on the scene with Patient #4 at 4:40 PM. The report further revealed, "...Dispatched to [SNF #1] for a 49 YOF [year-old female] that had a seizure and had hit her head on the bedroom wall... Staff directs [EMS crew] to pt [patient] room... where pt was still lying in her bed A&O x 3 [alert and oriented times 3; to person, place and time]. Pt is typically nonverbal according to NH [nursing home] staff. Pt does not answer any of our questions or respond to [EMS] crew, other than opening her eyes during questions and conversation...assessment is unremarkable, other than golfball-sized lump on top left, rear-side of pt's head... pt tolerated transport well and without incident... pt and stretcher are unloaded and taken into facility without incident... moved from stretcher to bed... secured... Pt care and report given to [RN #2] at bedside..." The report showed the patient arrived at Hospital #1 at 5:13 PM.

5. Medical record review for Patient #4 revealed a Pre-Arrival Summary was completed by Registered Nurse (RN) #1 on 5/19/2024 at 5:17 PM. The summary revealed, "Chief Complaint: Sent from [SNF #1], report from [named SNF #1 staff RN]... Full code... normally follows directions poorly, shuffles when walking, has limited interactions, talks when she wants and talks in the 3rd person, was up walking and had seizure and fell, knot to left back of head, left pupil less reactive than right, history of epilepsy, schizophrenia, DMII [diabetes mellitus type 2]..."

A triage assessment was completed by RN #2 on 5/19/2024 at 5:20 PM and revealed, "...Chief Compliant Descriptions: had seizure at [SNF #1] in bed and fall out of bed against wall... Functional Pain Scale: No pain... ED PTA [prior to arrival] Medic Procedures: Glucose check, Saline lock initiated..."

There was no documentation RN #2 read the Pre-arrival summary (sent from SNF #1) which included Patient #4's prior level of functioning and a full description of how the fall occurred prior to completing the triage assessment.

A nursing assessment was documented by RN #3 at 5:23 PM and revealed, "...Patient sent in via EMS for seizure. Nursing facility states patient was in the bed when she had a seizure and she fell and hit her head on the wall. Patient speaks few words baseline. Patient is alert to sound. Patient has a hematoma on her head without any bleeding... non verbal... Alert... Neurological Signs... Seizures Orientation: No change from baseline... Extremity Movement: Equal... Pupils Equal and Reactive to Light, and Accommodation: Yes... Gait: Unable to assess..."

There was no documentation RN #3 read the Pre-arrival summary (sent from SNF #1) which included Patient #4's prior level of functioning and a full description of how the fall occurred prior to completing her assessment.

Patient #4 was seen by ED Provider #1 at 5:49 PM. The Provider documented, "...Entirety of history obtained from report as patient is nonverbal. Reportedly patient had a seizure and fell out of the bed struck her head against the wall. Has a hematoma noted to her scalp. She was sent to the emergency department for further evaluation of head injury in seizures. Reportedly has history of seizure disorder... Additional review of systems information: Unable to obtain due to: Clinical condition... Physical Examination... Alert... Head: Normocephalic, 4 centimeter x 3 centimeter hematoma without laceration to occipital scalp. Neck: Supple Eye: Extraocular movements are intact, normal conjunctiva... Musculoskeletal: No swelling, no deformity Neurological: Alert, cooperative..."

There was no documentation to indicate whether or not the patient's musculoskeletal movement and strength were assessed.

All lab work and CT results were back by 6:08 PM and were reviewed by ED Provider #1 who documented, "...Medical Decision Making... Documents reviewed: Emergency department records, prior records... History Obtained from other than patient EMS, Diagnostic tests Discussion radiology... Admission not indicated, patient stable for discharge with outpatient follow-up, Brief Synopsis Patient is at baseline functional neurologic state at this time No emergent findings noted on physical exam... Suspect breakthrough seizure... Radiology results... CT Head without contrast... Impression: Mild low-attenuation changes in the periventricular deep white matter (affecting the small blood vessels within the brain). I believe are remote microvascular infarcts...Impression and Plan Breakthrough seizure... Scalp hematoma... Discharged to a nursing home..."

There was no documentation ED Provider #1 read the Pre-arrival summary which included Patient #4's prior level of functioning and a full description of how the fall occurred.

There was no documentation the patient's neurological status was reassessed prior to her discharge from the ED at 7:09 PM.

6. Review of the EMS report from EMS Service #2 dated 5/19/2024 revealed the ambulance unit was dispatched to Hospital #1 at 6:47 PM and was on the scene with Patient #4 at 7:05 PM. The report further revealed, "...Paged to the above location [Hospital #1] for discharge transfer to [SNF #1]... crew [EMS team] found a 49 y/o [year-old] female lying...in hospital bed alert but non-verbal. Staff stated they "didn't get a very thorough report from the nursing home" and were "pretty sure that non-verbal was her normal status due to psychiatric history". Hospital staff contacted EMS for Transport due to needing medical attendant for fall history and psychiatric issues. Pt had been brought in by county EMS for new onset of seizure-type activity. CT was performed and showed negative results... Assessment performed... Pt was alert but non-verbal, Pupils PERRL, airway patent... PMS [pulse, motor, sensory] intact in all extremities. Pt was asked to raise left arm to remove BP [blood pressure] cuff and she complied... moved to cot via drawsheet method...required no treatment during transport... Vitals remained stable within pt's normal limits... Pt moved to bed via drawsheet method...care was transferred by verbal report... Pt would turn her head and look at providers but would not respond verbally when asked for signature for transport... AEMT [advanced emergency medical technician]... asked why the pt was bedbound for paperwork reasons and he was advised that "She's normally walking and talking."..."

7. Review of a Progress note for Patient #4 from SNF #1 dated 5/19/2024 at 10:45 PM revealed, "...back from er at 730 via transport and placed in bed by emts, lethargic, had seizure in er and received 1000 mg of keppra and 1 liter of LR [lactated ringers], cat [CT] scan showed small hematoma, difficult ro [to] do neuro checks due to lethargy, eye open occ [occasionally]... talking, but lethargic..."

Review of a Progress Note for Patient #4 from SNF #1 dated 5/19/2024 at 11:37 PM revealed, "...continuing to monitor, assessing for movement of exts [extremities], no major movement of exts as of yet, resident very lethargic, toes will wiggle on both feet when bottom of foot tickled..."

Review of the SBAR Communication Form for Patient #4 from SNF #1 dated 5/20/2024 revealed, "...change in condition: change in neuro checks... Mental Status Evaluation (compared to baseline...): No changes observed... Functional Status Evaluation (compared to baseline...)... Decreased mobility... Describe the decreased mobility: Recent onset not resolving spontaneously... Body language Relaxed... Neurological Evaluation (compared to baseline...) Weakness or hemiparesis... Describe the weakness/hemiparesis: Weakness, arm or leg: Abrupt onset of noticeable change in strength or use... Summarize your observations and evaluation: went to er for fall returned with no movement to exts... Reported to Primary Care Clinician... 5/20/2024 Time (am) 00:00 [12:00 AM]..."

Review of a Progress Note for Patient #4 from SNF #1 dated 5/20/2024 at 1:21 AM revealed, "...12:45, hospital called and spoke with nurse in er, asked if resident was moving exts during er visit, nurse stated she was not moving..."

Review of a Progress Note for Patient #4 from SNF #1 dated 5/20/2024 at 1:41 AM revealed, "...NP... notified of residents neuro assessment, resident not moving to painful stimuli in any ext... orders to be sent back to ER..."

Review of the 911 call log dated 5/20/2024 at 1:52 AM revealed, SNF #1 called 911 regarding Patient #4. The log showed, "...Primary Incident Code... Fall/Back Injury... Resident fell prior and was sent to the ER and was sent back... She is not ambulatory... Only has a response from her eyes... No response to painful stimuli... She has been back sense 730 PM...ER stated she had small hemotoma [hematoma]..."

8. Review of the EMS report from EMS Service #1 dated 5/20/2024 revealed the ambulance unit was dispatched to SNF #1 at 1:54 AM and was on the scene with Patient #4 at 2:05 AM. Further review revealed, "...dispatched to above address for 49 YOF that had fallen due to a seizure and had hit her head. [Same EMS crew] had already transported this Pt to [Hospital #1] on an earlier call for the same C/C [chief complaint]... told by NH [nursing home] staff that the Pt had a seizure earlier and had fallen from her bed and hit her head. Pt had the same 5.08 cm [centimeters] hematoma on her head from earlier fall. The nurse [SNF staff] advises [EMS crew] that the Pt was now unresponsive to painful stimuli. AEMT... checks Pt's reflexes, to which the Pt does not respond. Pt will respond with a smile, and by saying yes, when AEMT... asks if she is okay. Pt is moved from her bed to the stretcher by two man sheet lift without incident... secured in stretcher... taken and loaded into ambulance without incident...places Pt on monitor to obtain VS. All VS are found to be WNL for this Pt... performs assessment, and all findings are noted in above. Pt assessment findings...saline lock in Pt's left hand, that was successful on first attempt...begins transport... Pt tolerates transport well, and without incident...Pt and stretcher are unloaded and taken into facility... directed to place Pt in ER room 9. Pt is moved from stretcher to hospital bed by two man sheet lift without incident... Pt care and report given to [RN #4] at bedside... NOTE: [EMS Service #2] transferred the Pt from [Hospital #1] back to {SNF #1] after being cleared by [Hospital #1] CT scan from previous visit and before this call. [EMS crew] was also advised by [Hospital #1] that Pt had fallen, during previous seizure episode, in the hallway at [SNF #1] while talking to the nurse. NH staff had moved Pt from where she had fallen, and placed her back in her bed..."

9. Medical record review for Patient #4 revealed a triage assessment was completed by RN #4 at 2:45 AM who documented the chief complaint was a "fall, no response to pain...Functional Pain Scale: No pain..."

A nursing assessment was documented by RN #4 at 2:56 AM and revealed, "...pt presents from Nursing Home with c/o [complaints of] not walking and not responding to painful stemuli [stimuli]. Pt is noraml/ly [normally] no verbal but will walk. Pt had a fall today and was seen in the ER. Pt was medically cleared treturn [to return]. Nursing home sent pt back because she is not walking. pt has no s/s [signs and symptoms] of distress no signs of pain...Alert Affect/Behavior: Appropriate, Calm, Uncooperative, Withdrawn..."

Patient #4 was seen by ED Provider #2 at 3:05 AM. The Provider documented, "...49 yr [year] old with history Schizophrenia, seizures, PTSD [Post Traumatic Stress Disorder] from childhood trauma, and anxiety presented with AMS [altered mental status]. Per NH. pt had a seizure this am (Per RN triage, pt had seizure in bed and rolled out striking back of head). pt noted hematoma back of head. Pt seen in ER and CT was neg. pt loaded on keppra and IVFs [IV fluids]. Pt sent back to ER [NH]. Staff states pt baseline is non verbal but walking. Pt looking around but wont move arms or legs. pt brought back to ER for evaluation. pt noted spont [spontaneous] eye opening in ER... 0345hrs [3:45 AM]; MD called NH: pt baseline is shuffle unassisted gait (no walker) through hallways. limited verbal phrase ie. [such as] "Yay" and "Why you do that"... does not hold a conversation. Does answer yes and no formation well. pt today limited movement in arms and legs. This am pt was walking down hallway when another resident say [saw] her started shaking like a seizure then fall backwards striking back of head... Physical Examination... Alert, spont eye opening. moving lips and tongue, non verbal baseline... Eye: Pupils are equal, round and reactive to light... Musculoskeletal: pt pulls back left leg with babinski flexion test, no change in movement with pin prick tool... Medical Decision Making... Admission indicated, patient workup resulted in criteria for observation/admission to the hospital, Brief Synopsis Will transfer to higher level of care for evaluation... 0440hrs [4:40 AM]: Pt placed in c colar [collar]. Position of comfort. Discuss case with NeuroSx NP [neurosurgery nurse practitioner]. Babinski test [a test that tests for central nervous system problems]: noted left leg draws inward, no toe flare noted on left foot. right leg no leg movement. toes curl inward right foot. No hyper reflex noted on Achilles or patella. no movement with pin wheel trial. No hyper reflex bicep to tricep b/l [bilaterally], Pt does hold left arm across chest when placed, right arm flaccid, left leg flaccid. 051hrs [5:51 AM]: NeuroSx... believed pt need higher level of care with complex spinal sx [services] availability...Impression and Plan: C2 cervical fracture... Hematoma of parietal scalp... Condition: Guarded... Disposition: Medically cleared, Discharged: Transfer to [Hospital #2]..."

Review of the Medical Necessity Certification Statement for Ambulance Services dated 5/20204 revealed, "...Medical necessity Questionnaire...C2 FX [fracture]/Paralized [paralyzed]..." Patient #4 left the hospital via ambulance at 6:20 AM.

10. Review of the EMS report from EMS Service #2 dated 5/20/204 revealed the ambulance was dispatched to Hospital #1 at 6:00 AM and was with the patient at 6:15 AM. Further review revealed, "...Arrived on scene...advised she is non verbal, she was walking down the hallway when she began having a seizure and fell backwards hitting her head. Advised patient was taken to ER that night and Er did CT of head and discharged patient. Nursing home staff noticed patient not able to walk and not in her normal status. Patient was sent back to ER, diagnosed with C2 fracture with paralysis in all four extremities...opens eyes and looks at you when speaking to her, non-verbal, paralysis of all four extremities...moved to stretcher...maintained c-spine...transport began...patient lifted her right arm a few inches above stretcher, became more awake and speaking inappropriate words...no other assessment changes during transport...Arrived at destination...wheeled to assigned ER trauma room...Verbal report was given...then they signed transfer of treatment/care..."

11. Review of Patient #4's Admission History and Physical obtained from Hospital #2 dated 5/20/2024 at 8:45 AM revealed, "...presents after a fall and reportedly hit her head. She was taken to an outside hospital and found to have no injuries and transferred back to her facility however they noticed she was unable to walk and was not moving any of her extremities, so she was taken back to the outside hospital where imaging revealed C2 injury ....she is opening her eyes spontaneously however she does not blink her eyes to commands. She does not respond. She appears alert however she has no movement response to pain ...Physical Examination ...Neurologic ...difficult to assess in the setting of possible quadriplegia and history of nonverbal she does not follow commands with her eyes however she moves them freely ..." X-rays were obtained of the chest and pelvis as well as CT scans of the head, C-spine, chest abdomen and pelvis. A CT Angiogram of the brain and neck were also completed. A BMP and CBC were collected. Further review of the History and Physical revealed, "...Impression/Plan...Injuries: BL [bilateral] pars interarticularis fx extending into the articular facet Foreign body in the C/3 interdisc space Ventral epidural hematoma from skull base to C3/4 BL luminal irregularity of the vertebral arteries at C2..."

Patient #4 was admitted to the hospital and had not been discharged as of 6/4/2024.

12. During an interview on 5/29/2024 at 3:00 PM, RN #3 verified she was the primary nurse for Patient #4 during her first visit to the ED on 5/19/2024. RN #3 was asked how often neurological checks were usually performed when patients presented to the ED with a head injury. The RN stated every 15 minutes, then every hour until cleared by the physician. RN #3 then verified she didn't document doing any other neuro checks on the patient after her initial assessment. The RN was asked if she was aware Patient #4 had a seizure while she was walking in the hallway and fell backward and hit her head. RN #4 stated, "No." She was informed by the Triage nurse (RN #2) that the patient had a seizure and hit her head on the wall. RN #3 stated the patient was at her baseline based on the information she was given by the triage nurse (RN #2).

During an interview on 5/29/2024 at 3:10 PM, RN #4 verified he was the primary nurse for Patient #4 during her second visit to the ED on 5/20/2024. RN #4 stated the patient had been seen in the ED earlier and was sent back to the nursing home. The nursing home sent her back because she wasn't walking or standing or responding to painful stimuli. RN #4 was asked if Patient #4 had another fall after her first visit in the ED. RN #4 stated, the patient didn't have another fall and he was told she had some sort of seizure activity and fell and hit her head in the hallway. RN #4 continued and stated, "[RN #2] got a different report; they [ER staff during the first visit] were told the patient fell out of bed and hit her head on the wall." The RN stated, "When I saw her [Patient #4] her vital signs were stable. She was making baseline noises from her mouth. She had some movement in the right upper arm." RN #4 continued and stated the patient had no movement at all in her left arm and both legs. RN #4 stated he "ran scissors on her legs with no response." The RN stated he informed ED Provider #2 and got orders for blood work and a CT of the head and CT of the cervical spine. RN #4 continued and stated, the "C-spine wasn't done earlier. [1st ED visit on 5/19/2024]; that's when we found the break [C2 fracture]." The RN stated he was informed the patient was going to be transferred to Hospital #2. RN #4 was asked if Patient #4 had a cervical collar in place during her visit to the ED. The RN stated, there was no collar in place upon her arrival, but he placed a cervical collar on the patient after the C2 fracture was confirmed by CT.

During an interview on 5/29/2024 at 3:20 PM, ED Provider #2 stated Patient #4 came in initially and it was reported she had a seizure and rolled out of bed. The Provider continued and stated, "Staff [SNF #1 staff] was concerned she wasn't moving her arms and legs since the 1st visit, so I told them to send her back. She wasn't moving her arms, legs, or head. I added a neck CT after I examined her and saw she wasn't moving anything. I got to the patient at 3:05. I had ordered the head CT at 3:00. I did my neuro exam and I recorded she was nonverbal status and didn't respond, pupils were equal and reactive...positive Babinski response. At 3:07 I ordered the C-spine. I didn't think it was a simple seizure and fall out of bed." ED Provider #2 continued and stated because of the confusion as to how the injury occurred, he called SNF #1 himself and asked what the patient was doing before the incident. The Provider stated he was informed the patient normally walked with a shuffling gait without a walker and walking down the hallway, had a witnessed seizure, fell backwards and hit her head on the wall. The patient didn't fall out of bed and hit her head. ED Provider #2 stated, "At that point, I'm concerned about a neck injury. A C-collar was applied." The Provider stated he got a "Red Alert" from CT regarding the fracture. The Provider consulted with neurosurgery who recommended the patient be transferred to Hospital #2, a Level 1 trauma center for further evaluation and treatment.

During an interview at SNF #1 on 5/30/2029 at 8:05 AM, the SNF Administrator stated Patient #4 had been a resident in the facility since 2013. The Administrator continued and stated the patient had a seizure and fell against the wall and her pupil wasn't reactive, so they sent the patient to the ED. The patient was sent back to the SNF and said she had a hematoma. The night shift nurse noticed a change in the patient's condition, so the patient was sent back to the ED. The Administrator continued and stated Patient #4 wasn't a full "walkie talkie" but she was able to walk with a shuffling gait and she would talk when she chose to.

During a telephone interview on 5/30/2024 at 10:12 AM, ED Provider #1 verified he was the Provider who evaluated and treated Patient #1 during her first visit to the ED on 5/19/2024. The Provider stated he spoke with ED Provider #2 the night Patient #4 returned to the ED [5/20/2024]. The Provider stated ED Provider #2 had called him and asked him what they had done for the patient during the first ED visit. The Provider was asked what he could recall regarding Patient #4. The Provider stated the patient had a seizure and had fallen out of bed and hit her head. ED Provider #1 was asked if he assessed the patient's strength and reflexes in her arms and legs. The Provider stated, "I couldn't get her to participate in doing strength exercises; she was responding to pain from what I could tell." The Provider continued and stated he obtained blood work, and head CT and gave the patient Keppra and "everything seemed fine." ED Provider #1 was asked if he considered obtaining a Cervical spine CT. The provider stated "I didn't have any concerns. I wasn't given any reports that she was ambulatory [prior to arrival]." ED Provider #1 was asked how he determined the patient was at her "baseline" neurologically. The Provider stated, "I was not informed she was able to ambulate prior to her arrival." ED Provider #1 was asked if Patient #4 was moving her arms and legs while she was in the ED. The Provider stated, "I don't recall her being flaccid or anything. I didn't write it."

During a telephone interview on 5/30/2024 at 10:25 AM, the Medical Director of Emergency Services (MDES) verified he had reviewed Patient #4's medical record. The MDES was asked if he found any concerns regarding the care and treatment