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Based on document review and staff interviews, the hospital's emergency department (ED) staff failed to follow the hospital's policies when the ED staff failed to provide an adequate medical screening examination for 1 of 40 patients (Patient #7) that presented to the ED and requested care. Failure of the hospital's ED staff to provide an ongoing/adequate medical screening examination within the hospital's capabilities resulted in the hospital's ED staff delaying the diagnosis of a patient who required a return to the ED the next day with symptoms of a stroke. The hospital's administrative staff identified an average of 693 patients presented to the ED and requested emergency care per month.

Findings include:

1. Review of the hospital policy titled "EMTALA," dated December 11,2018, revealed in part, "...HCHC is a hospital with an emergency department and shall provide to any individual, including every infant who is born alive, at any stage of development, who "comes to the emergency department" an appropriate Medical Screening Examination ("MSE"). The Medical Screening Examination is done within the capability of HCHC's emergency department and will include ancillary services routinely available to the emergency department, to determine whether an emergency medical condition ("EMC") exists, regardless of the individual's ability to pay. The EMTALA obligations are triggered when there has been a request for medical care by an individual within our dedicated emergency department ("DED"), when an individual requests emergency medical care on HCHC property other that in a DED (i.e. maternity services), or when a prudent layperson would recognize that an individual on HCHC property requires emergency treatment or examination, though no request for treatment is made. If an EMC is determined to exist, HCHC shall provide both (i) further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available to HCHC or (ii) an appropriate transfer to another medical facility...."

2. Review of the medical record revealed Patient #7arrived at the hospital's emergency department by ambulance on 3/7/19 following an unwitnessed fall at the local nursing home along with a change in gait (walk) from what was normal. Documentation from the nursing home record indicated staff contacted an ambulance to transport patient # 7, who had a history of dementia and received medication to treat essential hypertension (high blood pressure that can lead to stroke) following an unwitnessed fall. The ambulance crew documented the patient's blood pressure was 197/106 (normal blood pressure range is 120/80 - 140/90). While in the ED the patient received an x-ray of the right knee and the right hip. The x-rays results revealed no fractures. No other studies were ordered. Documentation in the medical record indicated staff did not check (deferred obtaining) patient #7's vital signs, including blood pressure and heart rate prior to discharge.

3. Review of a second medical record showed patient # 7 returned to the ED approximately 24 hours after discharge with impaired speech, facial drooping, and weakness in the right leg and arm. A CT scan (special type of x-ray) demonstrated patient # 7 had suffered a stroke. Staff arranged patient # 7's transfer to a hospital with a stroke unit.

Refer to 2406 for additional information.

Based on document review and staff interviews, the hospital's emergency department (ED) staff failed to provide an ongoing/adequate medical screening examination for 1 of 40 patients (Patient #7), selected for review, that presented to the ED and requested care from 2/8/19 through 4/6/19. Failure of the hospital's ED staff to provide an ongoing/adequate medical screening examination within the hospital's capabilities resulted in the hospital's ED staff delaying the diagnosis of a patient who required a return to the ED the next day with symptoms of a stroke. The hospital's administrative staff identified an average of 693 patients which presented to the ED and requested emergency care per month.

Findings include:

1. Review of Patient #7's closed medical record revealed Patient #7 arrived by ambulance at the hospital's ED on 3/7/19 at 8:13 AM with the complaint of an unwitnessed fall from a chair onto a tile surface.

Review of the 3/7/19 nursing home documentation showed Patient #7 had a diagnosis of Essential Hypertension (high blood pressure) and Dementia. Further documentation on 3/7/19 at 6:35 AM showed Patient #7 was found on the floor in her room, was incontinent of urine, had an unsteady gait, and was noted to be dragging her right leg. Staff at the nursing home contacted the physician who ordered transport by ambulance to the local hospital.

Review of the pre-hospital 3/7/19 ambulance trip report showed the ambulance crew were paged to the local nursing home to transport a patient with a change in gait. Further documentation showed Patient #7 fell and had weakness and difficulty walking. At 7:47 AM, the ambulance crew obtained the patient's blood pressure and documented it was 197/106 (normal range for blood pressure is 120/80 - 140/90). Upon arrival to the emergency department, documentation showed that the ambulance crew turned the patient's care over to the ED nurse and physician, who was also present.

Review of Patient #7's medical record revealed upon admission to the ED that the patient denied pain. Vital signs at 8:36 AM included a Blood Pressure of 156/80, heart rate 75, and respiratory rate 18. Patient #7's usual medications included medications for the diagnosis of essential hypertension. Patient #7 signed the consent for treatment on 3/7/19 at 9:19 AM.

Review of ED Physician A's documentation for Patient #7 on 3/7/19 at 11:37 AM showed physical exam - neuro: No motor deficit. No sensory deficit. Reflexes normal. Right hip and right knee x-ray did not reveal any broken bones. ED Course of Care: Patient was ambulated in ED. Appears to be favoring right hip though denies pain.

Patient # 7 was discharged on 3/7/19 at 10:28 AM to their prior living arrangements, but the patient was unable to sign the form indicating they received discharge instructions on 3/7/19 at 10:24 AM.

Review of Patient #7's medical record revealed the ED staff did not order or obtain any laboratory studies or an EKG. Documentation at the time of discharge (10:28 AM) showed "BP deferred, HR (heart rate): deferred, RR (respiratory rate) deferred, O2 saturation (oxygen saturation): deferred, Temp (temperature): deferred ...".

The evidence in the medical record showed the hospital failed to provide patient # 7 with an examination sufficient to determine that an emergency medical condition did not exist. Documentation showed the patient had a diagnosis of dementia and essential hypertension (high risk for stroke) and had fallen in the nursing home and was "favoring right hip." Documentation from the nursing home record did not specify how the 3/7/19 fall occurred because it was "unwitnessed." Documentation in the medical record specified the patient's fall while at the nursing home was unwitnessed, but included the following description of the fall, patient # 7 fell off a chair, slipped, fell onto a tile surface", and that staff at the "care center thought she was limping but not sure with right or left." Staff further documented they talked to the patient about her condition, diagnosis and need for follow up. The medical record did not contain evidence staff contacted the nursing home for baseline information on the patient's cognition, ability to walk independently, events that led to the fall, changes in her gait, or her medical condition including her blood pressure prior to or after her fall.

Review of a second medical record showed patient # 7 returned to the ED approximately 24 hours after discharge with impaired speech, a facial droop, and difficulty standing and walking. A CT scan (special type of x-ray) of the brain showed that patient # 7 had experienced a stroke. Staff arranged transfer to another hospital for stroke care.

2. During an interview on 4/9/19 at 4:00 PM, ED Physician A stated Patient #7 did not have any neurological deficits during examination in the ED on 3/7/19. The patient was alert and oriented and did not have any signs of facial drooping (a sign of a stroke) or any complaints of pain. Physician A stated Patient #7 told him she did not need to come to the ED. ED Physician A confirmed he did not obtain a CT scan (special type of x-ray) of patient # 7's brain.