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Based on staff interviews, medical record review, and review of facility policies and procedures, it was determined that the facility was not in compliance with §489.24 as evidenced by failure to ensure: 1.) a medical screening examination is conducted and a triage level is assigned as per facility policy on a patient presenting to the Emergency Department (ED) with documented symptoms of a stroke (A-2406); and 2.) a suicidal or psychological assessment is completed in accordance with facility policy for patients who exhibit self-injurious behaviors (A-2406).

Cross Reference:
489.24(a)(1)(i) - Medical Screening Exam

Based on staff interviews, medical record review, and review of facility policies and procedures, it was determined that the facility failed to ensure that 1.) a medical screening examination is conducted and a triage level is assigned as per facility policy on a patient presenting to the Emergency Department (ED) with documented symptoms of a stroke; and 2.) a suicidal or psychological assessment is completed in accordance with facility policy for patients who exhibit self-injurious behaviors.

Findings include:

1.) Facility policy titled, "Stroke, Treatment of Acute Ischemic," last reviewed 5/6/24, states, "IV. Identification. 1. Stroke and stroke-like symptoms may (SLS) include, but are not limited to, sudden onset of: 1. Focal weakness ...7. Dizziness ...V. Response ...a) Emergency Department ...1) Patients arriving with stroke-like symptoms will be triaged as per triage policy. a) Patient assigned a bed as soon as possible b) Notify the ED Physician/Resident/Advanced Practice Clinician immediately c) Stroke order sets utilized d) STAT blood glucose and CT head obtained e) Appropriate labs obtained f) Tele Neurology consult initiated as needed if within the 24-hour window of onset of symptoms g) Appropriate disposition made for admission/Transfer ..."

On 6/9/24 at 6:33 PM, P15 arrived in the ED. At 6:39 PM, S33 (ED RN) documented in the "ED Triage" the patient, "arrives for generalized weakness and dizziness x [times] 2 hours - pt [patient] states went to bathroom for bowel movement and was dizzy before and after." Vital signs were documented, and an EKG (Electrocardiogram) was performed at 6:46 PM. A "General Assessment" was completed, and the triage nurse documented "Yes" to "Does the patient have any stroke symptom."

At 10:38 PM, a registered nurse documented for P15, under "Waiting Room Patient" that the "Waiting Room [was] checked. Patient called x3" with the first time called listed as 2229 [10:29 PM], three hours and fifty-six minutes after P15 arrived in the ED. At 10:38 PM, the nurse entered the patient's ED disposition as "Left without being seen."

An interview was conducted on 9/25/24 at 2:29 PM with S32, Stroke Coordinator. S32 discussed signs and symptoms of a stroke and stated, "early signs would be balance issues, dizziness, weakness, vision changes, and speech difficulties." S32 explained the protocol for caring for a stroke patient, stating, "the triage nurse, who is NIH [National Institute of Health] certified, will bring back the patient to the doc bubble immediately for rapid assessment with the physician. An initial NIH score will be documented, and this process only takes a few minutes. A CAT [Computerized Axial Tomography] Scan and neurology consult would be ordered, vital signs would be taken every 15 minutes, and lab work including an INR [International Normalized Ratio] would be completed and resulted within 45 minutes." S32 confirmed that a patient who exhibited signs and symptoms of a stroke would be assigned an acuity level of 2 or higher. P15's chart was reviewed in the presence of S32, who confirmed that the patient should have immediately been brought back to the "physician bubble" to be assessed.

The medical record lacked documentation that the facility's stroke policy was followed.

2.) Facility policy titled, "Suicide Risk Assessment (Pt. Safety)," last reviewed 12/04/2023, states, " ...RN [Registered Nurse] screens all patients age 12 and above for suicidal ideation during triage. The Columbia Suicide Severity Rating Scale (C-SSRS) is completed for every patient with suicidal ideation. In situations where the patient is unable to respond to questions and has exhibited self-injurious behavior such as drug overdose, RN initiates 1:1 Observation until suicide attempt and/or suicidal ideation can be ruled out ..."

On 6/1/24 at 11:31 AM, P20 was brought to the ED by ambulance. At 11:34 AM, S47 (ED RN) documented in the "ED Triage, ...pt found on steps of doctors office with empty bottle of rubbing alcohol next to [him/her] ..." Vital signs were documented, and an EKG was performed. A "General Assessment" was completed by the triage RN who documented "unable to obtain" to the question, "do you want to hurt yourself." P20 was assigned an acuity level of "2". P20 was examined by the physician (S46) at 11:37 AM and diagnosed with "altered mental state; isopropyl alcohol poisoning." A CT (Computed Tomography) of the face, spine, brain, and head were completed, an IV (intravenous) catheter was placed, fluids were administered, ABGs (Arterial Blood Gas) taken, and a chest x-ray was completed. The patient was placed on "1:1 observation Non-Suicidal" at 12:06 PM. A "Psychosocial Assessment" completed by the ED RN at 12:00, showed the patient as having a "flat, impulsive, restless" affect, "disheveled" appearance, and "not coping." A physician note, written at 5:39 PM by S31 (ED Physician), states, " ...Patient has significant improvement in [his/her] mental status. [He/She] is fully alert and oriented ...I anticipate that the patient will likely elope or sign out AGAINST MEDICAL ADVICE from this emergency department. Patient has capacity to do so on my assessment. Another note, written by the physician at 7:53 PM, states, "Patient has achieved clinical sobriety. [His/Her] withdrawal symptoms are adequately controlled. I strongly encouraged [him/her] to stay for discussion with the recovery coach and detoxification. However, patient adamant declines ..." The patient signed "Against Medical Advice" (AMA) paperwork and left the ED at 7:57 PM.

P20's medical record was reviewed in the presence of S6, Director of the ED, and an interview was conducted on 9/26/24 at 10:08 AM. S6 stated he/she would consider ingesting rubbing alcohol as "probably a self-injurious behavior" and "we would contact our behavior health." S6 confirmed that the physician did not perform a psychological or suicidal assessment.

The medical record lacked documentation that the physician performed a suicidal or psychological assessment in accordance with facility policy for patients who exhibit self-injurious behaviors.