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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on observation, interview, and record review, the facility failed to ensure the availability of emergency supplies when the facility's emergency department did not have a plan in place to ensure immediate access to working IV (intravenous infusion) pumps, during emergency procedures possibly delaying care and treatment, placing patients at risk of worsening symptoms, including death.

Findings include:

During a telephone interview, on 2/24/23 at 3:20 pm, Patient #1 stated, "The neurologist said I needed tPa (used to dissolve blood clots during strokes), it was very time sensitive. They kept bringing in different pumps, they didn't work."

During a tour of the facility's emergency department, on the morning of 2/28/23, an IV pump was seen sitting on the nursing station counter. Staff #9, ED Clinical Director stated it was not working and had a staff member remove the pump from service.

During an interview, on the morning of 2/28/23, in the facility's emergency department, Staff #9, ED Clinical Director stated, "We don't have enough pumps to go in every room. If the nurse needs a pump, they have to look in the other rooms to find one not in use. We tag broken pumps, materials will come and take them. We are in the process of purchasing new pumps; they are not the same as the old ones, they don't make them anymore. We don't want to put out the new pumps until we have enough for the whole hospital."

Staff #9 confirmed this process can delay the care to patients.

EMERGENCY SERVICES POLICIES

Tag No.: A1104

Based on interview and record review, the facility failed to establish a policy and procedure for the treatment of patients presenting with a stroke or neurological deficit for 2 out of 15 patients reviewed (Patients #1 and #2), delaying care and treatment placing patients at risk of worsening symptoms, including permanent paralysis and death.

Findings include:

During a telephone interview, on 2/24/23 at 3:20 pm, Patient #1 stated, "I came in by ambulance. I couldn't lift my arm and my speech was slurred. I was seen by a NP (Nurse Practioner), she ordered a CT (Computerized tomography), it came back clear. The NP came in 3 hours later and told me I was going to be discharged home; I insisted I was not ready for discharge. A neurologist was consulted, he examined me and said I was having a stroke and was a candidate for tPA (used to dissolve blood clots during strokes), it was very time sensitive. I had an MRI (magnetic resonance imaging) the next day, it showed I had a stroke."

Review of Patient #1's medical records reflected Patient #1 was transported to the ED on 12/29/22 at 12:54 pm.
The Nurse Practioner examined the patient at 1:04 pm and reassessed the patient at 3:25 pm.

Review of Patient #1's supervising physician's note dated 12/29/22 at 5:18 pm reflected, "This is a 35-year-old male patient recently seen by nurse practitioner who was brought in by ambulance for acute onset of moderate and constant since onset left arm numbness and weakness that began around this afternoon while the patient was at the grocery store. Patient was originally seen in the fast-track area however, due to concerning symptoms and time of onset, tele neurology was paged (contacted) by midlevel due to symptoms and imaging. Shared decision making was made between tele neurologist and family at bedside."

Review of Patient #1's Neurologist assessments dated 12/29/22 at 3:37 pm reflected,
"National Institutes of Health Stroke Scale:
1a) LOC: 0- Alert
1b) Orientation: 0- Answers both correctly
1c) Commands: 0- Performs both tasks correctly
2) Best Horizontal Gaze: 0- Normal
3) Visual Fields: 0- No visual field loss
4) Facial Palsy: 0- Normal symmetry
5a) Motor arm (Right): 0- No drift
5b) Motor arm (Left): 0- No drift
6a) Motor leg (Right): 0- No drift
6b) Motor leg (Left): 0- No drift
7) Limb Ataxia: 2- Ataxia in two limbs
8) Sensory: 1- Mild sensory loss
9) Language:0- Normal
10) Dysarthria: 1- Mild/moderate
1 1) Extinction/inattention: 0- None
TOTAL:4"

Patient #1's MRI of the brain was completed on 12/30/2022 at 1:14 pm and stated in part,
"IMPRESSION:
1. Several small foci of acute infarction involving the anterior left cerebellar hemisphere, left temporal lobe, and left occipital lobe.
2. Partially visualized known thrombus in the proximal left Pl segment with partial loss of the left PCA flow void.
3. Linear focus of restricted diffusion over the expected location of the left occipital horn lateral ventricle, unclear if representing small area of ependymal infarction or ventriculitis. Recommend correlation with CSF sampling."

Further review of Patient #1's medical record revealed the NP did not conduct the NIH (National Institutes of Health) Stroke scale, a tool used to assess for a potential stroke.

Review of the medical record for Patient #2 revealed Patient #2 presented to the ED at 12/15/22 at 1:00 am with a chief complaint of dizziness. Patient #2's history of present illness dated 12/15/22 at 2:12 am by the NP stated in part, "...presents today with left facial numbness, dizziness and diaphoresis that occurred after he ate dinner tonight. The patient states that the numbness has been occurring for several months... just found out today that he will have an MRI on Monday. The patient denies any injury or trauma..."

Further review of Patient #2's medical record revealed the NP did not conduct the NIH (National Institutes of Health) Stroke scale.

During an interview, on the morning of 2/28/23, in the facility's conference room when asked if the stroke scale was required for all patients with stroke like symptoms, Staff #10, ED physician stated, "Not all patients will require a full assessment, it is based on the bedside assessment too. The NIH stroke scale gives us a pathway to assess for a potential stroke."

During a telephone interview on, 02/28/23 at 8:30 am, when asked how the neurologist determines if a consult is needed, Staff #8, the facility's consulting neurology vice president, stated, "We rely on the facility to call us for consults. We don't know what we don't know. We do not have a process for stroke activation. The NIH stroke assessment is conducted by the Neurologist. The CT is the first line of testing, it is the standard. If we are consulted, we have access to the facility's electronic medical records system. Our physicians are Acute practitioners."

During a telephone interview, on the afternoon of 3/03/23, when informed Nurse Practioners did not receive the stroke training, Staff #13, CNO (Chief Nursing Officer), confirmed the NPs had not received the NIH stroke training from the facility and that the facility did not have a policy or procedure for the treatment of patients with stroke symptoms or neurological deficits. Staff #13 stated, "The new Stroke protocol will specifically address the Nurse Practioners seeing stroke patients. We immediately directed the Nurse Practioners to include their supervising physician for any patients being seen for stroke or neurological symptoms. They will be receiving further education with the neurologist."