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

Findings included:

1. The hospital's DED failed to provide an appropriate Medical Screening Examination (MSE), to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 37 sampled DED patients who presented to the hospital for evaluation and treatment of signs and symptomns of suspected stroke (Patient #4).

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination Condition, Tag A2406.

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, physician interview and staff interview, the hospital's DED failed to provide an appropriate Medical Screening Examination (MSE), to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 37 sampled DED patients who presented to the hospital for evaluation and treatment for signs and symptoms of suspected stroke (Patient #4).

Findings included:

Review on 08/29/2017 of the current hospital policy titled "EMTALA Policy", revised 12/2016, revealed, "...____(Hospital Name) is committed to complying with the Emergency Medical Treatment and Active Labor Act, 42 U.S.C 1395 and the implementing regulations (EMTALA). EMTALA requires that a hospital with an emergency department to provide to any individual who is not a patient of the hospital and who "comes to the emergency department" an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an EMC exists, regardless of the individual's ability to pay...Emergency Department Patient Medical Screening..Scope...An individual is considered to have "come to the emergency department" if the individual is not an Existing patient and: The individual has presented at a DED and requests examination or treatment for a medical condition, or has such a request made on his or her behalf."

A medical record review on 08/29/2017 for patient #4 revealed the 88 year-old female presented to the hospital's DED via private vehicle on 04/03/2017 at 1443 with a complaint documented as "Suspected Stroke...Per family, pt (patient) has had slurred speech and gait issues for one week." The documentation revealed the patient was triaged by DED RN #1 at 1443 who documented the patient was an "ESI (Emergency Severity Index) 3." At 1455 the review revealed the patient received an EKG (electrical recording of the heart) for suspected "TIA/Stoke" while in the triage area. Vital signs taken at 1449 in triage revealed the patient's pulse as "79" beats per minute and blood pressure as "133/77." With no documentation of the patient being brought into the DED treatment area, the DED Physician #1 documented at 1504 that the EKG interpretation for the patient as "Atrial Fibrillation/Flutter, Right Bundle Branch Block, Left Ventricular Hypertrophy, Anterior Infarct, Significant Rhythm Changes, Abnormal EKG." Documentation at 1645 revealed a fingerstick blood sugar for the patient was elevated at "170." The next documentation in the medical record was for vital signs being repeated at 1753 (Total of 3 hours and 4 minutes since triage vitals) by Nursing Assistant #1 with readings as "106" pulse (increased from 79) and blood pressure of "143/92" (increased). No documentation was found in the medical record that the nursing assistant made the nursing staff aware of the increase in the patient's heart rate.

Review of the hospital's current policy "Triage Process", revised 12/2016, revealed , "...Reassessment...Patients in the Emergency Department waiting room will have vital signs reassessed based on the triage acuity level: Category III- every 2 hours." Review of the patient's medical record revealed the patient's vital signs were reassessed at 3 hours and 4 minutes (Total of 1 hour and 4 minutes greater than 2 hour requirement) after being triaged as ESI #3 (Category III).

Further review of patient #4's medical record for 04/03/2017 revealed the patient was not given a room assignment and remained in the waiting room. The documentation revealed documentation from the DED RN #2 at 1929 that patient #4 was called in the waiting room with no answer. Documentation at 1934 by DED RN #3 revealed an overhead page was done in the lobby of DED twice with no patient answer. The review also revealed that DED RN #2 again documented calls for the patient twice at 1939 and three more times at 1945. The documentation revealed the patient left without treatment after the documentation revealed the patient was potentially in the DED waiting room with a complaint of suspected stroke and EKG reading as "Atrial Fibrillation/Flutter, Right Bundle Branch Block, Left Ventricular Hypertrophy, Anterior Infarct, Significant Rhythm Changes, Abnormal EKG" for a total of 5 hours and 2 minutes.

Interview on 08/30/2017 at 1305 with the DED Physician #1 revealed that he did read patient #4's EKG but did not see the patient on 04/03/2017. The physician revealed the patient had Atrial Fibrillation rate and stroke symptoms reported for a week. The interview revealed that if cardiac problems are a potential, then we do an EKG and it was up to the triage nurse for the order of patients to come back. The physician stated that he felt the patient had atrial fibrillation but not needing to have to be brought back in the DED and it was up to the triage nurse.

Interview on 08/30/2017 at 1630 with the DED RN #1 revealed that he was working as triage nurse on 04/03/2017 when patient #4 presented to the DED. The interview revealed his documentation revealed the patient presented with her family who were concerned the patient had a suspected stroke. The interview revealed the patient was triaged as ESI 3 and had an EKG done in triage area with DED Physician #1 reading the EKG. The interview also revealed that a fingerstick glucose was done to rule out low sugar levels for the patient as well as the patient's vital signs were normal during triage. The patient's neurological assessment was reported as done and no symptoms were noted by the nurse. The interview revealed "If we have full department, ESI 2s and 3s may go back to lobby." The interview also revealed that the nurse thought vital signs for ESI 3 was reassessed every 4 hours but he was not sure and would have to look at the policy. The interview also revealed that if patients in the lobby have abnormal vital signs, the nursing assistants should let the nursing staff know. The interview also revealed for patient #4, since the patient's pulse went from 79 to 106 on reassessment, the nursing assistant should have made the nursing staff aware of the changes. The interview indicated no documentation was found to indicate that the nursing staff was aware of the patient's change in heart rate. The interview further revealed that he got off of duty at 1900 on 04/03/2017 while the patient was still in the DED.

Interview on 08/31/2017 at 0840 with DED RN #3 revealed that she was the triage nurse on 04/03/2017 starting her shift at 1900. The interview revealed that she did not remember specifics about patient #4 but after reviewing the patient's medical record that she was the assigned triage nurse for 1900 during the patient's DED visit. The interview also revealed that she did not see any documentation nor did she remember the nursing assistant #1 reporting patient #4's vital signs to her for 1853. The interview also revealed that if the patient's "106" pulse change was reported to her that she would have addressed the change. The DED RN revealed that the nursing assistant was from the hospital's "Central Staffing" and that she may not have been as familiar as other nursing assistants in knowing to report vital sign changes to the nursing staff. The interview revealed the process in the DED is for the nursing assistants to report abnormal vital sign changes to the nursing staff for patients waiting in the lobby to be taken to the back.

An interview was attempted with nursing assistant #1 but the nursing assistant was no longer employed or available for interview.

In summary, patient #4 was brought to the hospital's DED on 04/03/2017 by private vehicle with her family who reported the patient had a suspected stroke with symptoms of slurred speech and abnormal gait for approximately 1 week. The patient was triaged as ESI 3 that included the patient having an EKG and fingerstick glucose taken in triage. The EKG that was read in the back by DED Physician #1 revealed the patient had an abnormal EKG that included significant changes and atrial fibrillation as the patient was placed in the lobby. The patient had triage vital signs taken with an reassessment of vital signs taken 3 hours and 4 minutes later with changes in the patient's pulse that increased from 79 to 106. No documentation was found that the nursing assistant reported the change of the patient's vital signs to either triage nurse while the patient was in the lobby. The nursing staff attempted to call the patient after the patient was documented as in the DED for a total of 5 hours and 2 minutes before being documented as left without treatment.