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Based on record review and interviews, the facility failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases, when it did not provide a complete medical screening examination (MSE) in one of 20 sample records (Pt#1) that were reviewed.

Refer to A2406 for additional information

Based on a review of record review and interviews, the facility failed to provide a complete medical screening examination (MSE) in 1 of 20 sample records (Pt # 1) that were reviewed. The facility did not perform and document a neurological consult, coagulation labs, National Institutes of Health Stroke Scale (NIHSS), and additional diagnostics-MRI when Patient # 1 returned a second time with the symptoms of severe headache, high blood pressure, and weakness, to determine if the patient was stable or had an emergency medical condition. Patient #1 went to Facility B on 09/21/2025 at 8:25 PM and was diagnosed with Cerebrovascular accident (CVA) and admitted inpatient for an emergency medical condition.

Medical Record

Facility A, Visit # 1 on 09/20/2024

A review of the document titled "Patient Medical Chart" for Patient # 1 revealed the patient arrived at the facility on 09/20/2024 at 2:00 PM.
The document titled "Triage Note" completed by Staff # 4, RN, on 09/20/2024 at 2:07 PM revealed Patient # 1 had head pain at a numeric rating of "5=moderate pain. "

A review of the document titled "History of Present Illness" by Staff # 1, MD Emergency Medicine, on 09/20/2024 at 3:19 PM revealed the following:
"A 49-year-old male presents to the ED today with complaints of headache that began upon waking up this morning. Has associated dizziness and bilateral leg weakness. Has family hx [history]of Barry aneurysm.
Review of Systems
Additional review of systems information: All other systems reviewed and otherwise negative." ...
" ...Inpatient Medications Ordered
Fioricet: 1 Tabs, Oral, Once-No notes on effectiveness
NS Bolus (ADULT): 1,000 mL, 983.61 mL/hr, IV Piggyback, Once
Reglan: 10 mg, 2 mL, IV Push, Once.."
..."Physical Examination
Cardiovascular: Regular rate and rhythm, Normal peripheral perfusion.
Neurological: No focal neurological deficit observed, normal speech observed.
Psychiatric: Cooperative, appropriate mood & affect.
Medical Decision Making
Differential Diagnosis: Migraine, tension headache, hypertension, dehydration, viral syndrome.
Rationale: 49-year-old male with severe headache. Computed Tomography (CT) independently reviewed and negative for gross bleed or mass. No focal neurologic deficits appreciated. Labs reviewed. Headache resolved after medication. Return precautions given. Will send home with primary MD follow-up.." ...
Diagnostics:
... "Electrocardiogram: Time 9/20/2024 14:11:00, rate 87, normal sinus rhythm." ...
Abnormal Labs:
... "Chloride 110 mmol/L HI [98-107]
Alk Phos 132 Intl_units/L HI [46-114]
CK 36 Intl_units/L LOW [46-171]

Head Computed Tomography: Time reported 9/20/2024 16:49:00, EXAM: CT Head or Brain w/o Contrast
IMPRESSION:
1. No acute intracranial pathology
2. Minimal sinus disease" ...
... "Reexamination/ Reevaluation
Time: 9/20/2024 17:10:00. Assessment: The patient had an elevated blood pressure reading during their visit today. I discussed their elevated blood pressure readings with the patient and we decided to have the patient keep a log of their blood pressure readings at home and follow up with their PCP.
Impression and Plan
Headache - ICD10-CM R51.9, Medical
Plan
Condition: Improved, Stable.
Patient was given the following educational materials: Self-Care for Headaches, Understanding Headache Pain, HYPERTENSION, To Be Confirmed.
Follow up with: Follow up with primary care provider Within 1-2 days.
Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Patient indicated understanding of instructions.
Disposition: discharge."

Facility A, Visit # 2 on 09/21/2024

A review of the document titled "EMS Patient Care Record" by Crew Lead on 09/21/2024 revealed the following:
EMS arrived at Patient # 1 home on 09/21/2024 at 8:15 AM. The patient was noted in a fetal position in his bed and was moved to a "cot." The patient had complaints of vomiting. The patient was administered 4mg of Zofran via a 20 gauge IV placed in the patient's left forearm. The patient was taken to the ambulance and loaded into it. The patient was also administered 15mg of Ketorolac and a saline bag via the IV. During transport, the patient had an episode of vomiting "orangish fluid." The patient was transported to Facility A and was transferred from the cot to a stretcher using a draw sheet. A verbal report was given to the ED Staff.

A review of the document titled "Assessments" by Staff # 6, RN-ED, on 09/21/2024 revealed the following:
Vital signs were as follows on 09/21/2024:
2:53 PM, Temperature was 97.3F, Pulse was 88, Respiration was 18, BP was 128/93-right arm, and SPO2 was 100% on room air.
1:29 PM, Temperature was 97.3F, Pulse was 91, Respiration was 18, BP was 129/101-right arm, and SPO2 was 95% on room air.
10:29 AM, Temperature was 97.3F, Pulse was 84, Respiration was 18, BP was 129/92-right arm, and SPO2 was 100% on room air.
9:16 AM, Temperature was 97.3F, Pulse was 82, Respiration was 18, BP was 139/92-right arm, and SPO2 was 98% on room air.

A review of the document titled "ED Physician Record" by Staff # 2, NP, on 09/21/2024 at 2:12 PM revealed the following:
... "9/21/2024 9:24 CDT Chief Complaint: Pt to Ed[ED] via Bryan CO from home, pt headache started this am again, given 15mg toradol and 4mg zofran pta [prior to arrival] by EMS. Pt seen here yesterday for same thing, having N/V[nausea/vomiting], ongoing migraines for approx 1 week. Pt seen here yesterday for same thing, having N/V:
9/20/2024 14:07 CDT Chief Complaint: the patient has been having migraines x[for] about a week. states that both of his legs just completely gave out. states this morning, the migraine was bad." ...
... "History of Present Illness
The patient presents with headache and dizziness. The onset was this am. The course/duration of symptoms is constant. Location: Left parietal. Radiating pain: none. The character of symptoms is achy and throbbing. The degree at onset was moderate. The degree at maximum was moderate. The degree at present is moderate. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none. Prior episodes: occasional. Therapy today: see nurses notes. Preceding symptoms: none. Associated symptoms: nausea, vomiting and photophobia. Additional history: seen yest[yesterday] for headache and had ct[CT] scan.. ems[EMS] records reviewed- zofran and toradol and ns[normal saline] bolus by ems.. mother had barry aneurysm at age 40.. no injury. no fever.." ...
Review of Systems:
... "Musculoskeletal symptoms: Negative except as documented in HPI.
Neurologic symptoms: Headache, dizziness.
Psychiatric symptoms: Negative except as documented in HPI." ...
Physical exam:
... "Back: Nontender, Normal alignment, no step-offs.
Musculoskeletal: Normal ROM, normal strength, no tenderness.
Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed.
Lymphatics
Psychiatric: Cooperative, appropriate mood & affect.
Medication provided:
DexAMETHasone 10 mg IV Push
diphenhydrAMINE (Benadryl) 25 mg IV Push
Sodium Chloride 0.9% intravenous 1000 mL IV Piggyback
prochlorperazine (Compazine) 10 mg IV Push
butalbital/acetaminophen/caffeine
(Fioricet) 1 Tablet Oral
methocarbamol (Robaxin) 1000 mg IV Push
ondansetron (Zofran) 4 mg IV Push
meclizine (Antivert) 25 mg Oral
diazePAM (Valium) 5 mg IV Push
Abnormal Labs:
WBC 10.26 x10e3/mcL HI
Neut % Auto 84.70 % HI
Lymph % Auto 9.90 % LOW
Neut # Auto 8.69 x10e3/mcL HI
Lymph # Auto 1.02 x10e3/mcL LOW
Sed Rate 16 mm/hr HI
Glucose Level 121 mg/dL HI
Potassium 4.9 mmol/L HI
Chloride 113 mmol/L HI
BUN 8.0 mg/dL LOW
BUN/Creat Ratio 6.7 LOW
Alk Phos 118 Intl_units/L HI
9/21/2024 12:37 CDT SARS-CoV-2: Negative" ...
... "Impression and Plan
Dizziness - ICD10-CM R42, Medical[billing term]
Other headache syndrome - ICD10-CM G44.89, Medical[billing term]
Elevated blood pressure reading - ICD10-CM R03.0, Medical[billing term]
Plan
Condition: Improved, Stable.
Prescriptions: sent to the Pharmacy.
... "Patient was given the following educational materials: DIZZINESS, Unknown Cause, VERTIGO, Unspecified, Self-Care for Headaches [and a stroke screen].
Limitations: activity as tolerated..
Follow up with: NEU[Neurology] Within 3-5 days.
Counseled: Patient, Family, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions, return if not improving."

The facility failed to perform and document a neurological consult, coagulation labs, National Institutes of Health Stroke Scale (NIHSS) assessment, and additional diagnostics when Patient # 1 returned a second time with the same symptoms.

... "Discharge Request (Order): 9/21/2024 14:11 CDT, Home Routine, Dispositioned by: DC Home, Patient care was supervised by: Staff # 7."

Facility A failed to recognize the symptoms of Patient # 1, who arrived for both visits to Facility A's ED on 09/20/2024 and 09/21/2024.
Symptoms documented for 09/20/2024 by Staff # 1, MD, in the ED Physician Record were: "patient has been having migraines x[for] about a week. states that both of his legs just completely gave out. states this morning, the migraine was bad. "

Patient # 1's second visit to Facility A revealed the following: The patient arrived at the ED via EMS with complaints of a headache that had been ongoing for a week, nausea, vomiting, and dizziness. These symptoms are noted as constant; an associated symptom was photophobia. This was acknowledged in Staff # 2, NP's "ED Physician Record," dated 09/21/2024 at 9:23 AM.

Facility A failed to recognize these symptoms, and a CTA, MRI, and a PT/INR PTT were not ordered to help diagnose a stroke.

Patient # 1, Facility B, University of Texas Southwestern Medical Center (UTSW)

A review of the documentation for Patient #1's stay at Facility B, on 09/21/2024 revealed the following:
Arrival Date/Time: 09/21/2024 8:25 PM
Medical Screening exam: 09/21/2024 at 9:21 PM
Adm. Date/Time: 09/21/2024 11:12 PM

A review of the "ED Provider Notes" by Staff # B1, MD on 9/21/2024 2121 revealed the following:
... "Organ system impairment: Neurovascular given evidence of acute cerebellar stroke, large volume with evidence of large vessel occlusion of the left vertebral V3/V4 [artery] segment portending significant risk of morbidity and mortality. Vital sign derangements/lab abnormalities: Tachycardia, large ischemic posterior infarct on MR [MRI], V3/V4 segment vertebral artery, large vessel occlusion on CTA
Interventions: Stat MRI, stat neurology consultation, neurocritical care unit admission to monitor for cerebral edema
Emergency Medicine Attending Physician Note
CC:
Chief Complaint
Patient presents with:
o Generalized Weakness
With HA [headache]x 10 days, nausea. Per pt[patient] family, pt has been seen by neurologist in the past week for bilateral upper extremity pain and HA- reports testing, CT[computed tomography] scan and EEG[electroencephalogram] WNL[within normal limits]. Worsening generalized weakness today/continued HA (denies change in character)- pt unable to get to restroom unassisted." ...
... "HPI[History of present illness]: male with PMHx[past medical history52[49]y/o male[correct date of birth is 8/10/1975]as below who presents with headache, onset 10 days ago, severe, associated with 36 hours of vertigo (room-spinning, supposedly intermittent but severe and unable to open eyes due to severity). States he has been seen at outside hospital x 2 and possibly by a neurologist for which has undergone CT and EEG that were reassuring. Due to persistent symptoms, family decided to seek an additional opinion. Patient reports associated numerous episodes of NBNB[non-bloody, non-bilious] emesis. Also states that at time of onset of dizziness yesterday morning, he had a brief period of vision loss that sounds like a left visual field deficit that improved slowly over a couple of hours. No associated speech changes, numbness or weakness of limbs." ...
... "Vitals: 09/21/24 2027
BP: (!) 157/91
Pulse: 99
Resp: 16
Temp: 36.3 °C (97.4 °F)
TempSrc: Temporal
SpO2: 98%
Weight: 79.4 kg (175 lb)
Height: 1.829 m (6')
Physical Exam
Constitutional: Well-developed and well-nourished. Answers questions appropriately. Patient appears in significant discomfort.
Head: Normocephalic and atraumatic. Mouth/Throat: Oropharynx clear; mucosa moist. Eyes: Non-icteric; pupils equal round, reactive.
Neck: Neck supple, trachea midline
Cardiovascular: regular rate and regular rhythm without MGR; distal pulses 2+
Pulmonary/Chest: No respiratory distress; breath sounds clear without WRR, effort normal
Abdominal: Soft, non-tender, non-distended without masses or guarding
Musculoskeletal: No deformity, no edema.
Neurological: AOx3, PERRL, EOMI, right-sided nystagmus, CN 2-12 intact, facial symmetry, grip strength 5/5 bilaterally, hip flexion 5/5 bilaterally, gross sensation intact throughout, abnormal FNF on the left
Skin: Warm and dry, no rash noted
Psych: Mood and affect normal
52[49]y/o male[ correct date of birth is 8/10/1975] with PMHx as above presenting with headache with associated vertiginous symptoms. Headache onset 10 days ago, vertigo approximately 36 hours ago. At time of onset of vertigo, there was no associated left-sided visual field deficit that resolved slowly over the course of a couple of hours. Tachycardic but vitals otherwise acceptable. Evaluated at an outside hospital and by neurologist with CT and EEG that were reassuring against acute pathology. Given persistence of symptoms and general concern for posterior ischemic infarct based on active vertiginous symptoms and positive hints exam, plan for MR[Magnetic resonance imaging], CT/CTA [computed tomography/Computed Tomography Angiography." ... ... "MRI reveals a large left-sided cerebellar infarct. CTA with left V3/V4[vertebral arteries] segment large vessel occlusion. Neurology consulted who agrees to admit."
"Discharge Information
Date/Time: 09/26/2024 4:10 PM Disposition: To Rehab Unit Destination
Provider: Unit: Staff # B2, Acute Stroke Unit

Policy

A review of the document titled " PC_251 Stroke Alert." The last approval date was 03/11/2024; pages 2 and 3 revealed the following:
"Emergency Department Activation:
1. Triage nurse assesses patient for signs and symptoms using BEFAST tool, determines LKW, and rules out stroke mimics."
Facility A failed to document the utilization of the BEFAST assessment tool during both visits to screen for a stroke. The assessment included screens for balance, vision, facial appearance, arm weakness/numbness, speech, and inability to speak. This tool was included in the discharge paperwork for the patient's visits on 09/20/2024 and 09/21/2024.

A review of the document titled " PC_251 Stroke Alert." The last approval date was 03/11/2024, Page 3 revealed the following:
"Level 1 code stroke orders include the following:
1. CT brain without contrast
2. CTA of head and neck and /or CT perfusion for patients that meet LVO criteria
3. Labs: CBC, PT/INR, PTT, BMP, Troponin, and HCG[pregnancy test] if female and childbearing age)
4. EKG
5. NIH Stroke Scale [identifies a stroke severity and monitors for neurological changes over time]
6. POC glucose
7. Continuous monitoring of EKG, BP, and 02 saturations
8. Oxygen to keep saturations> 94%"


Interviews:

1. An interview with Staff # 2, NP, Emergency Department, on 01/28/2025 at approximately 1:45 PM revealed the following:
I remember this patient; he was in a curtained room on 09/21/2024. I was not told about him not being able to walk. I heard about his headache and being dizzy. I saw him, and he said he had a headache (HA); a family member was giving me information. The patient had no prior history of headaches. I looked at yesterday's notes[9/20/2024] and saw I gave him medication for dizziness. Also, I saw he had Labs and a scan completed. On 9/21/24, I added more information to my notes and gave the patient more medication; the patient said his pain was relieved. A CT was not repeated as the medication relieved the symptoms. I did not observe him walk; he never said he couldn't walk.

2. An interview with Staff #5, LVN, on 01/28/2025 at approximately 2:23 PM revealed the following:
A male came in on 09/20/2024 with complaints of being dizzy, headaches, and nausea. He was taken to a curtain room with a recliner chair. He was in the recliner. I started an IV and took labs. The wife came out and told me something was wrong with her husband. I went to see him, and he was crying. I asked what was wrong, and he said he "didn't feel normal; something was off." I reclined him in the chair. I told the Charge RN, then told. The doctor said I'll give him something for nausea and fluids. Later, the patient didn't want to lie down anymore. I said ok, and he sat up. Later, I asked him and his wife how he was doing, and both said he was doing fine. He said the meds worked great. He walked well, opened the car door, and transferred to the car without assistance.


Legend:
Emergency Department-ED
History-hx
NS-normal saline
ml/hr-milliliter per hour
Computed Tomography-CT
mmol/L -Millimoles per liter
Intl_units/L-international unit per liter
PCP-Primary Care Physician
EMS-Emergency Medical Service
IV- Intravenous
BP-blood pressure
SPO2- Peripheral capillary oxygen saturation (the oxygen level in your blood)
CDT- Central Daylight Time
Bryan CO- Bryan County, Oklahoma
N/V-nausea/vomiting
Approx.-approximately
am-morning
HPI-history of present illness
WBC-white blood count
Neut % Auto-Neutrophils in the blood
Lymph-Lymphocyte in the blood
Sed Rate-Sedimentation Rate
BUN/Create Ratio- urea nitrogen in your blood/ Creatinine Ratio
ALK Phos- Alkaline Phosphatase
CTA- Computed Tomography Angiography
MRI- Magnetic Resonance Imaging
PT/INR-Prothrombin Time/International Normalized Ratio (blood lab)
PTT- Partial Thromboplastin Time (blood lab)
HA-headache
EEG-electroencephalogram
PMHx-past medical history
NBNB- non-bloody, non-bilious [emesis]
BEFAST tool - warning signs for a stroke: Balance, eyes, face, arms, speech, and time.
LKW-last known well
LVO- Large Vessel Occlusion