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Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, "Stroke Alert Activation - Emergency Department [SAAED]," for one of five sampled patients (Patient 23). This failure had the potential for Patient 23 to receive delayed care and negative health outcomes.

Findings:

During a review of Patient 23's "Result Details," dated 5/15/24 at 15:12 (3:12 p.m.), the "Result Details" indicated, "Events: G1P0 [indicates one pregnancy and no births], 38+1 wks [weeks], pt [patient] of [clinic] here w/[with] c/o [complaint of] pelvic pain and possible leaking. Also c/o blurred vision and left sided numess [sic] at 1400 [2 p.m.] and a headache since then. Pt reports +fm [positive fetal fibronectin, (protein formed during pregnancy) can signify an increased risk for premature birth], denies bleeding or uc's [uterine contractions]. Denies complications w/ preg [pregnancy] or gen [general] health."

During an interview on 7/24/24 at 9:41 a.m. with Nurse Manager of Labor and Delivery (NMLD), the NMLD stated obstetrical (OB-relating to childbirth and the processes associated with it) patients can come to the front hospital lobby to be seen in the obstetrical emergency department (OB ED). NMLD stated if an OB patient came to OB ED for evaluation and their complaints included left-sided weakness, OB patient would be seen by the triage nurse (ED nurse establishes type of care patient needs and priority to be seen). The provider (medical professional) would be notified, and the provider would determine what to do, once the Medical Screening Exam (MSE, to determine if there is an emergency situation) was completed and the patient and baby were stabilized. Then OB staff would move the patient to the Emergency Department (ED) for further non-OB evaluations. NMLD stated OB ED was an umbrella under the ED chain.

During an interview on 7/24/24 at 9:50 a.m. with Director of Nursing for Labor and Delivery (DONLD), the DONLD stated a Rapid Response Team (RRT-team to help when a patient's condition changes) would be called for OB patients who present with stroke-like symptoms and the OB nurse would follow the patient and baby. DONLD stated RRT would start the stroke process since OB ED did not have the stroke alert packet in the department which includes the Vision, Aphasia [speech difficulties] Neglect [VAN] scale [an assessment tool for stroke].

During an interview on 7/23/24 at 12:44 p.m. with ED Nurse Manager (EDNM), EDNM stated Patient 23 should have been sent to ED to be evaluated for her blurred vision, left sided numbess, and headache. EDNM stated this patient could had been seen in the ED for non-OB complaints and OB ED could come over to evaluate her and baby in the ED.

During a concurrent interview and record review on 7/24/24 at 1:20 p.m. with NMLD, Patient 23's "OB Triage [OBT, assigns priority of care]," dated 5/15/24 at 15:12 (3:12 p.m.) was reviewed. The "OBT" indicated, "Chief Complaint: pelvic pain and maybe leaking, also blurred vision, left-sided numbness and a headache. . .OB ESI [Emergency Severity Index, patient assessment tool] Level: 4 - Non Urgent. . .Triage [assigns priority of care]. . .Neuro [relating to nerves or the nervous system] Symptoms: Headache, Visual disturbances. . .Contractions, Per Patient: No. . .Leaking Fluid, Subjective: Unsure. . .Risk Factors, Antepartum [around time of birth] Current Preg: None." NMLD stated she would expect the nurse to call RRT for OB patients who are having difficulty speaking and have one-sided weakness on "physical assessment."

During an interview on 7/24/24 at 4:19 p.m. with Director of Quality Management and Patient Safety (DQMPS) 1, DQMPS 1 stated OB ED was part of the ED. DQMPS 1 stated OB ED staff follow the P&P titled "Stroke Alert Activation - In-Patient, not the P&P titled "Stroke Alert Activation-Emergency Department" as in ED.

During an interview on 7/29/24 at 3:15 p.m. with Quality Program Specialist Program Manager (QPSPM) 1, QPSPM 1 stated OB ED nurses were not trained on the P&P stroke alert activation - ED, since they were Labor and Delivery (L&D) nurses.

During an interview on 7/29/24 at 3:16 p.m. with NMLD, NMLD stated the RRT nurses would be the ones to complete the VAN and start the stroke packet.

During an interview on 7/29/24 at 3:20 p.m. with OB ED Triage Nurse (OBEDTN), the OBEDTN stated if a pregnant patient came to the OB ED with pelvic pain and maybe leaking, also blurred vision, left-sided numbness and a headache, she would call RRT to rule out a stroke. OBEDTN stated she would wait for the RRT nurse to start the stroke assessments since she was not very familiar with it.

During an interview on 7/29/24 at 4 p.m. with Chief Nursing Executive Officer (CNEO), CNEO stated OB nurses did follow the inpatient stroke alert activation P&P.

During a review of the facility's RN Emergency Services Job Description (RNESJD), dated 3/10/20, the "RNESJD" indicated, "Responsibilities. . .8. PERFORM OTHER RELATED JOB DUTIES. . .8.4 Care and management of stroke patients."

During a review of Patient 23's "Physician Note [PN]," dated 5/15/24 at 15:51 (3:51 p.m.), the "PN" indicated, "History of Present Illness. . .AT 38 WEEKS PRESENTED [came] WITH HISTORY OF TRANSIENT [lasting only for a short time] HEADACHES AND LEFT ARM NUMBNESS SIMILAR TO PREVIOUS EPISODES OF MIGRAINE [a headache of varying intensity, often accompanied by nausea and sensitivity to light and sound] HEADACHES. NO PHOTOPHOBIA [light sensitivity] OF [sic] DIPLOPIA [double vision] . . .Triage Plan: TO ED FOR EVALUATION MIGRAINE.

During a review of Patient 23's "[PN]," dated 5/15/24 at 18:05 (6:05 p.m.), the "PN" indicated, The patient presents with headache. The onset was 2 [two] hours ago. The course/duration of symptoms is worsening ..."

During a review of Patient 23's "ED Triage [EDT]," dated 5/15/24 at 16:13 (4.13 p.m.), the "EDT" indicated, "Chief Complaint ED: blurred vision, headache and left-sided numbness. . .Reason for visit: NEURO."

During a review of the hospital's website, the hospital's website indicated the hospital was a Certified Stroke Center. The hospital's website indicated "Stroke is the third leading cause of death in the United States and the leading cause of disability. But fast treatment can reduce or even prevent disability. Remember, with stroke, time is essential. When you or someone you love is having a stroke, every minute counts. We are a fully-accredited Stroke Center ..."

During a review of policy and procedure titled, "Rapid Response Team (RRT)," dated 6/24/24, the P&P indicated, "POLICY: 6. Criteria for staff to call the RRT is as follows: i. Suspicion of Acute Stroke 1) Sudden numbness or weakness. . .5) Sudden severe headache. . .7. An attempt to notify the managing/attending physician of patient condition should always be made in conjunction with activating the RRT."

During a review of the facility's policy and procedures (P&P), "SAAED," dated 4//26/24, the P&P indicated, "POLICY: The purpose of this policy is to identify the process for a Stroke Alert activation in the Emergency Department (ED), as well as define the roles and responsibilities of personnel, in order to provide timely and effective care to patients presenting with stroke symptoms. . .DEFINITIONS: 6. Stroke Alert is an alert that is paged out to initiate the emergent treatment of patients who present to the hospital with stroke symptoms. a. The signs/symptoms of stroke may include, but are not limited to: 1) Weakness and/or numbness on one side of the body. . .5) Sudden visual disturbance. . .9) Sudden, severe headache. . .PROCEDURE: 1. EMERGENCY DEPARTMENT (ED) STROKE ALERT ACTIVATION. . .b. A stroke alert will be called for patients presenting to the ED with acute onset of stroke symptoms and meet one of the following criteria. . .2) Their symptoms started less than 24 hours prior to their arrival. C. A stroke alert can be initiated by. . .ED provider, Charge RN, RN Navigator, or Triage RN. d. Activation occurs by ED staff dialing "77" announcing "Bakersfield Memorial" notifying the operator and reporting the location of the Stroke Alert. . .ROLES and RESPONSIBILITIES DURING STROKE ALERT. . .a) ED Triage RN 1) Triage nurse reviews symptoms of each patient presenting at ED triage entrance 2) If stroke is suspected, performs a VAN assessment and documents on Stoke VAN form (Appendix A) 3) If a patient meets criteria for stroke alert, the triage RN notifies ED charge nurse of stroke alert for prompt physician and nurse review."