HospitalInspections.org

Based on hospital policy review, medical record review, and physician interview the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

The hospital's Dedicated Emergency Department (DED) qualified medical professional 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 8 sampled DED patients (#7) who presented to the hospital's DED with stroke symptoms, dizziness, or visual changes.

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

Based on policy and procedure review, closed medical record review, and physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including further imaging and testing, to rule-out a stroke and determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 8 DED patients who presented with stroke symptoms, dizziness, or visual changes. (Patient #7)

The findings include:

Review of the "EMTALA" policy, number NH-PC-CC-1132, effective April 2017, revealed "...II. POLICY....It is....policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state and federal laws....A. Medical screening examination 1. Individuals (including minors) entitled to a medical screening examination a) Individuals in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospitals' emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists....2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner....a screening process that is reasonably calculated to determine whether any emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individuals' presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures....C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition....4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. ..."

Closed medical record review, on 05/10/2017, revealed Patient #7, a 64 year old, arrived to the DED (Dedicated Emergency Department) by ambulance on 10/08/2016 at 1727. Review of the Patient Care Timeline report revealed the patient was placed in an ED room at 1732 and triage began at 1734. The Chief Complaint was recorded as dizziness and nausea, stating "Pt. (patient) has been nauseous and dizzy since last evening. Pt. states she vomitted (sic) several times last noight (sic), today had episode where she lost vision in her right eye for approx (approximately) 45 mins (minutes)." Vital signs, at 1736, were Temperature (T) 98.9 F (Fahrenheit), Heart Rate (HR) 69, Respirations (R) 18, Blood Pressure (BP) 176/74, SpO2 (blood oxygen saturation level) 98% on room air, and pain denied at that time. At 1739, review revealed Patient # 7 was assigned an acuity level of 3 (on a scale of 1-5, with 1 being the most severe).
Patient Care Timeline review revealed the Medical Screening Exam was initiated at 1753. Review of ED Provider Note, dated 10/08/2016 at 1904, revealed "...64-year-old female presents the emergency department complaining of vertigo, headache, and vision loss. The patient states that she has a history of a 'optic nerve stroke' a few years ago. She states that she had the loss of vision out of her right eye at that time. The patient states that her vision had improved in her right eye however returned to normal. Patient states that yesterday evening she began to develop some vertigo type symptoms. Her dizziness was worse with changing positions and standing upright. Her symptoms were significantly improved with rest and immobility. She states that her vertigo symptoms continued throughout the course of the day today. The patient was on her way driving to the airport when she had a fairly sudden onset of severe pain across the top of her head. The patient at that time had a significant worsening in her vertigo symptoms and developed nausea and severe vomiting. She had multiple episodes of vomiting in a short period of time. She also states that she had a loss of vision in her right eye similar to what she experienced at the time of her optic nerve stroke. She reported to urgent care who sent her to the emergency department for evaluation. She states that ....her head pain has resolved, as has her nausea, and her vision in her right eye has returned to its recent baseline. She still complains of mild vertigo symptoms. She has had no focal neurologic deficits. ....Review of Systems....Pertinent positives and negatives as per history of present illness. Remainder of 10 systems reviewed and are unremarkable....Gastrointestinal: Positive for Nausea and vomiting. Negative for blood in stool and diarrhea. Neurological: Positive for dizziness and headaches.... Physical Exam Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Eyes: EOM (extraocular muscles/movement) are normal. Pupils are equal, round, and reactive to light. No nystagmus (rapid, uncontrollable eye movement) Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate and regular rhythm....Musculoskeletal: Normal range of motion. She exhibits no edema or tenderness. Neurological: She is alert and oriented to person, place, and time. She has normal strength. No cranial nerve deficit or sensory deficit. ..."

Review of ED Provider Notes, at 1950, revealed "... Patient states that she had improvement of her vertigo symptoms with the Antivert. CT scan here was normal, laboratory studies showed no significant abnormalities. The patient has a history of similar vision loss in her right eye past. Her symptoms are primarily vertigo associated with an episode of severe head pain earlier today. These symptoms have all completely resolved and she has only mild residual vertigo at this time. The patient lives in the (City Name) area, has eye doctors and primary care physician there. She would prefer to be discharged tonight to follow-up with her physicians at home for any of her symptoms continue. I've instructed her to return to the emergency department if she has any further problems while staying in the area.... Patient progress: stable.... New Prescriptions DIAZEPAM (VALIUM) 5 MG [milligram] TABLET Take one tablet (5 mg total) by mouth every 8 (eight) hours as needed (vertigo).... MECLIZINE HCL (ANTIVERT) 25 MG TABLET Take one tablet (25 mg total) by mouth every 6 (six) hours as needed for Dizziness.... Final diagnoses: Vertigo Decreased vision....Disposition Discharge....Condition at discharge: Stable.... Please follow up.... Follow-up with your eye doctor and primary physician as soon as you get home for reevaluation. Return to the emergency department with any worsening of her symptoms or other concerning problems. ..." Patient Care Timeline review revealed Patient #7 was discharged at 2008. Review revealed "...Departure Condition: Improved; Discharge Instructions Reviewed with: Patient; Method of Teaching: Verbal; Written discharge instructions; Patient Teaching: Discharge instructions reviewed; Follow-up care reviewed; Prescription given to patient/support person. ..."

Telephone interview, on 05/10/2017 at 1500, with the physician who cared for Patient #7 in the ED (MD #1), revealed that in a situation like this patient's presentation, the sudden onset of symptoms was concerning. By the time the patient was examined in the ED, with the exception of the vertigo, everything returned to baseline. The headache was completely gone, he stated, vision had returned to baseline, and there were no neurological symptoms. Primary concerns, he stated, would be TIA or hemorrhage, that peripheral vertigo would be way down the list. Per MD #1, labs were ordered as was a head/brain CT. Interview revealed that, as he recalled, the labs were "ok" and the brain CT was normal. Interview revealed the newer generation of CT scanners, although not 100%, are very reliable. MD #1 stated that in looking at the documentation, the patient's symptoms were much improved, the Antivert had helped the vertigo, test results thus far had been normal, there was not an acute problem right then. More evaluation was needed to rule out other issues, with clinical options including spinal tap or MRI or admission. MD #1 stated Patient #7's doctors were in a different city/state and based on his documentation "it looks like she said she would prefer her doctors." Interview revealed MD #1 discharged the patient. She had concerning symptoms, he stated, but most had completely resolved, she was alert and oriented, was neurologically intact, and she "had a right to participate in her health care decisions". MD # 1 stated he felt the patient was stable for discharge with the understanding of the concerns and good reliable resources for follow-up care. Interview revealed that while he did not recall the conversation, based on documentation to follow-up "as soon as" she returned home, he would have reviewed his concerns and the importance of follow-up with Patient #7. Interview revealed MD #1 considered the exam to be thorough, stating he considered all the patient's symptoms, as well as the concerns going forward, and involved the patient in the decision.

In summary, Patient #7 did not receive an appropriate medical screening examination, as further imaging and testing was required to rule-out a stroke and assess for stroke risk factors. In addition, there was no evidence in the medical record of discussion of the risks and benefits of discharge prior to further testing.
NC00127227