HospitalInspections.org

Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to ensure an appropriate medical screening examination (MSE) and failing to provide stabilizing treatment for patients who presented to the emergency department seeking emergency medical care. Failure to perform an appropriate MSE and provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

The hospital failed to ensure an appropriate medical screening examination (MSE) was performed to determine if an emergency medical condition (EMC) existed 2 of 20 patients (Patient 1 and Patient 17) who presented to the emergency department (ED) seeking emergency medical care. (Refer to A2406 for details)

The hospital failed to provide stabilizing treatment for 2 of 20 patients (Patient 1 and Patient 17) who presented to the emergency department seeking emergency medical care. (Refer to A2407 for details)

Based on record review, policy review, document review and interview the Hospital failed to ensure an appropriate medical screening examination (MSE) was provided to determine if an emergency medical condition (EMC) exists 2 of 20 patients (Patient 1 and Patient 17) who presented to the emergency department (ED) seeking emergency medical care. The hospital's failure to ensure an appropriate MSE was completed has the potential for all patients to be discharged with an unidentified Emergency Medical Condition (EMC) which causes delays in necessary stabilizing treatment and may lead to deterioration of the person's condition, including harm and death.

Findings Include:

Review of a document title, "Rules and Regulations of the Medical Staff McPherson Hospital, Inc." approved by Governing Board on 10/15 ... showed, "The hospital must provide for an appropriate medical screening examination, to determine if an emergency medical condition exists, on all patients presenting to the emergency room. The following individuals have been determined to be qualified medical personnel to perform the medical screening examination: registered nurses assigned the responsibilities and duties of the emergency department and obstetrics, physician assistants who are members of the McPherson Hospital Allied Health Care Staff and McPherson Hospital staff physicians. MICT's have been determined to be qualified to perform the medical screening examination in the field in accordance with written protocols ..."


Review of policy titled "EMTALA (Emergency Medical Treatment and Active Labor Act)" revised 01/20 showed " ...SCREENING PROCEDURES: Whenever an individual comes to McPherson Hospital's emergency department requesting an examination or treatment, the individual shall be screened without delay to determine whether an emergency medical condition exists, as follows: EXAMINATION: The patient shall be examined promptly. The screen shall utilize all appropriate resources of the emergency department. The screening is to be recorded in the patient's medical records and in the emergency department's logbook and shall not be delayed in order to inquire about the individual's method of payment of insurance status ...
DEFINITION OF "EMERGENCY MEDICAL CONDITION". The screening shall be conducted to determine whether the individual has and "Emergency Medical Condition" which is defined under federal law as: A medical, psychiatric, severe pain or obstetric condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:

1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy: or
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part" ...

Review of a hospital policy titled, "Triage Policy" revised 11/20 showed, " ...Patients will be promptly and appropriately triaged based on the Emergency Severity Index (ESI) level 2 ...High risk situation danger zone vitals ...>8 y [years old] HR (heart rate) >100 RR (Respiration rate) >20 SaO2<92% delaying identification and treatment of an emergency medical condition ..."

Review of a hospital policy titled "Discharge Against Medical Advice" revised 07/22, showed " ... In the event a patient elects to discharge herself/himself from the hospital against the advice of the attending physician and of the hospital administration, she/he or the responsible party, is requested to sign the "Leaving the Hospital Against Advice" form ... The circumstances surrounding an Against Medical Advice discharge will be documented on the Nurses progress notes ... An Incident report will be completed and turned into the Risk Manager ..."

Patient 1

Review of Patient 1, medical record showed he presented to the ED on 12/23/22 at 10:12 PM via private vehicle with his wife with a chief complaint was dizziness for two weeks and slurred speech for two days. His wife states the slurred speech started this afternoon. Patient 1 past medical history included high blood pressure (force of blood is against the artery walls is too high), high cholesterol (high levels of fats in the blood), anxiety (feeling of worry and nervousness) and coronary artery disease (damage or disease in the heart's major blood vessels). Patient 1 was triaged at an Emergency Severity Index (ESI) 3 (stable and should be seen urgently).

Review of the "History" [History of Present Illness] showed " ...The patient is being seen for an acute stroke. The history is obtained from the patient and the patient spouse. Patient is 78-year-old male that presents with lightheadness [sic] present over the last two weeks. He states that yesterday started to notice some slurred speech. His wife noticed slurred speech today ..."

The "Physical Exam" showed, " ...Cranial nerves II-XII intact (A fiber tract emerging from the brain the trained examiner can localize lesions when abnormalities are found), sensation normal in all extremities, strength normal all extremities, patient speech does appear slightly slurred, but patient speaks with a stutter and without a baseline of his speech is difficult for me to tell definitively ..."

Review of the "Plan" showed, "Patient was discharged home. Offered patient admission to the hospital but I could not guarantee that standard work-up for stroke such as MRI (Magnetic Resonance Imaging - a non-invasive imaging technology that produces three dimensional detailed anatomical images), echocardiogram (a scan used to look at the heart and nearby blood vessels), and ultrasound of the carotids (arteries that supply blood and oxygen to the brain) would be available this weekend. We agreed that the patient would contact [Staff P, MD] patients primary care provider, and discuss getting his work-up done as an outpatient. Patient to return to the emergency department for any neurological changes. Patient was given a full aspirin prior to discharge."

Review of a document titled "[The Hospital] Hospital NIH [National Institute of Health] Stroke Scale (scale made up of 11 different element that evaluate specifically ability. The score for each ability is a number between 0 and 4, 0 being normal functioning and 4 being completely impaired) ...Baseline ...Best Language: 0- No aphasia (language disorder that affects the person ability to communicate can occur suddenly after a stroke] " showed, " ...Best Language: Ask patient to describe picture, name items; 0 [points] No aphasia 1 [points] Mild to moderate aphasia, 2 [points] Severe aphasia 3 [points] Mute; 10. Dysarthria Ask patient to read several words 0 [points] Normal articulation, 1 [points] Mild to moderate slurring of words 2 [points] Near unintelligible or unable to speak, 9 [points] Intubated or other physical barrier ...."

Review of a note dated 12/23/22 at 10:15 PM, "Neurologic" by Staff I, RN, showed " ...National Institutes of Health Stroke Scale (NIHSS); Dysarthria (slurred or slow speech that can be difficult to understand): 0- Normal Speech ...NIHSS Total Score: 0; Notified Provider: 12/23/22 10:16 PM; Pts [Patient] wife reports pt has "slurred speech", Slurred speech not noted during assessment but RN (Registered Nurse) notes pt seems to stammer or elongate pronunciation of the first letter of some words."

The medical record showed Patient 1 discharged on 12/24/22 at 12:10 AM with a disposition of home or self-care with dismissal instructions for Slurred Speech follow up with primary care physician.

The hospital failed to ensure an appropriate MSE was completed per hospital, "Transient Ischemic Stroke (TIA) Order Set" " ...Carotid Doppler ultrasonography (procedure that uses sound waves to examine blood flow on each side of the neck) imaging within 48 hours, CTA (computed tomography with special dye or contrast), or MR angiography (a powerful magnetic field to elevate blood vessels and help identify abnormalities), or Transcranial Doppler (test that use sound waves to detect problems with blood flow in your brain) within 48 hour ..."
Patient 1's medical record failed to show Patient 1 left Against Medical Advice (AMA) after being advised by the physician the need for admittance to the hospital.

Review of Patient 1's medical record MRA (procedure that uses radio waves and a powerful magnet linked to a computer to create detailed pictures of the blood vessels and blood flow inside the body) and MRI was completed on 12/27/22 at 11:57 AM approximately 83 hours post discharge from the ED. The Carotid Ultrasound was done on 12/28/22 at 2:58 PM approximately 110 hours post discharge delaying identification and treatment of an emergency medical condition.

During interview 06/12/23 at 10:00 AM with Staff A, Chief Operating Officer, (COO) states "MRI can be called in after-hours but they are not on call."

During an interview on 06/13/23 at 9:40 AM, Family Member 1 (F1), Patient 1's spouse, stated, " ...By 10:00 PM that night he was not speaking right and slurring his speech and getting worse and he always has correct pronunciation ... We told them the exact time frame when it started. They told us that they could admit him. The doctor told him that since it was Christmas that he would have to wait for MRI (magnetic resonance imaging), so my husband decided to go home ..."

During an interview on 06/13/23 at 3:30 PM, Staff F, Doctor of Medicine (MD), stated, " ...If the patient is out of the stroke window and the CT scan of the head is negative, we would give an aspirin, and we would admit to hospital if it's a first-time stroke for an ultrasound of carotids and echocardiogram (ultrasound of the heart) if they don't meet the transfer requirements ... If I tell a patient that they would need to be admitted and they refused I would have them sign out Against Medical Advice (AMA)."

During an interview on 06/14/23 at 8:40 AM, Staff M, RN, Executive Director of Nursing, stated, " ...The NIH the provider is supposed to do the NIH scale, but the nurse can also NIH scale..."

During an interview on 06/14/23 at 11:50 AM, Staff A, COO, stated " ...We do not require the NIH education for nurses since we are not a stroke center..."

During an interview on 06/14/23 at 2:17 PM with Staff O, Executive Secretary, stated " ...The Physicians don't have NIH education ..."

Review of Patient 1's medical record "Clinic Intake" [office notes] Stroke Follow up dated 12/29/22 at 2:59 PM " ...Discussed MRI findings and MRA [completed on 12/27/22 at above named hospital] findings showing the area in the cerebellum (stroke that reduces oxygen delivery causes motor and balance control) and right basilar artery occlusion (a stroke that can cause dizziness, headaches and speech especially dysarthria and difficulty articulating words) which is not amenable to any kind of treatment such as stenting (opens a clogged artery) etc. ..."


Patient 17

Review of Patient 17's medical record showed a 74-year-old female presented to the Emergency Department (ED) on 06/05/23 at 12:28 PM with a chief complaint was shortness of breath. Patient 17's past medical history included Chronic Obstructive Pulmonary Disease (COPD) (respiratory symptoms like progressive breathlessness and cough), Hypertension (elevated blood pressure), Hyperlipidemia (high levels of fats in the blood), and Asthma (airway inflammation). Patient 17 was triaged at an Emergency Severity Index (ESI) 3 (stable and should be seen urgently).

Patient 17's "History" [History of Present Illness]" showed, "The patient is being seen for dyspnea (shortness of breath). The history is obtained from the patient, the patient's family and 74-year-old female states that she started to become short of breath last night worse today. She reports a cough of dark brown and yellow sputum for the past week and a half family and patient conflicted on how new this is or how different is from her baseline she says that it is at her baseline family says it is perhaps of increased frequency. There is [sic] been no sick contacts. She has tried a breathing treatment about 1 hour prior to arrival. She denies other associated signs and symptoms. She is not on oxygen at home. Onset was (sic) patient continues to smoke has known history of COPD."

The physical exam dated 06/05/23 at 12:46 PM showed Staff G, MD, documented ... "Thorax and Lungs" Patient has end expiratory wheezes (continuous lung sound with a musical quality heard during expiration) and prolonged expiratory phase (respiratory muscles normally relax during exhalation) in all lung fields there is no rhonchi (low-pitched rattling lung sounds) appreciated. Cardiovascular Regular rate and rhythm, no murmurs, gallops or rubs, regular rate and rhythm, S1 and S2 (heart sounds) normal, no murmurs, gallops or rubs ..."

Review of a document dated 06/05/23 at 12:44 PM titled, "Vital Signs" showed Staff E, RN documented, " ...Temperature: 96.5 F (35.8 C) Temporal (normal Temperature 98.6); Pulse: 105 bpm (beats per minute) (normal 80-100 bpm); Pulse Ox 02 Saturation: 86 % (The amount of oxygen circulating in your blood, normal between 95% and 100%); Respiration: 22 breaths/min (normal 12-20 breaths/min.); Blood Pressure (BP): 131/77 Sitting (normal BP less than 120/80), R Arm;..."

Review of a document dated 06/05/23 at 12:51 PM titled, "ED Nursing Documentation Physical Assessment Respiratory" showed Staff E, RN documented, " ...Airway Clearance: Patent; Breathing Pattern: Labored, Short of breath Cough: Barking, Hacking, Dry; Left Lung Sounds: Rhonchi; Right Lung Sounds: Rhonchi ..."

Review of a "Plan" dated 06/05/23 at 1:33 PM showed Staff G, MD documented, "Per EMTALA, this patient was given a medical screening exam and the condition was (sic) did not have access to vitals prior to examining the patient who is (sic) vital signs seem to improve my (sic) arrival. I told the patient there is plenty of clinical data to recommend blood work and consideration for admission. She would prefer to go home she lives 5 minutes from home (sic) and has good social contact she will buy a pulse oximeter and return if worse. I considered sepsis after reviewing her initial vital signs but I feel she is clinically improving and a reasonable outpatient candidate for both pneumonia and COPD exacerbation with close PCP (Primary Care Provider) follow-up and good return precautions."

The medical record showed Patient 17 discharged on 06/05/23 at 1:40 PM with disposition of home or self-care.

The Hospital staff failed to ensure Patient 17 was triaged appropriately based on the Triage Policy that showed, " ...Patients will be promptly and appropriately triaged based on the Emergency Severity Index (ESI) level 2 ...High risk situation danger zone vitals ...>8 y [years old] HR (heart rate) >100 RR (Respiration rate) >20 SaO2 <92%, delaying identification and treatment of an emergency medical condition ..."

The medical record failed to show any laboratory testing was completed on 06/05/23 between 12:28 PM through 1:40 PM.

Prior to discharge on 06/05/23 at 1:40 PM, the hospital staff failed to include a reassessment of vital signs that showed Patient 17 had a documented Heart Rate <100, Respiration rate <20, and/or Oxygen Saturation (The amount of oxygen circulating in your blood) between 95% and 100%) or a functional test such as an ambulatory oxygen saturation evaluation for stability after presenting with "Bilateral pneumonia with acute on chronic pulmonary obstructive disease with acute exacerbation moderate, nicotine dependence."
Patient 17's medical record also failed to show Patient 17 left Against Medical Advice (AMA) after being advised by the physician the need for admittance to the hospital.

During an interview on 06/14/23 at 9:07 AM, Staff G, MD stated that if a patient does not want to be admitted, I would verbally tell them and document all the treatments and risks of leaving and have them sign out AMA.

Review of Patient 17's medical record dated 06/05/23 at 4:33 PM showed Patient 17 returned to the Emergency Department with complaint of, "I can't breath [sic] again." Two hours and 53 minutes from discharge.

Review of a document in Patient 17's record dated 06/05/23 at 4:48 PM titled, "Cardio-Pulmonary Resuscitation" showed, "Pt [Patient 17] in tripod position (sitting or standing leaning forward supporting upper body with hands or knees due to respiratory distress) saying she can't breathe requested 02 be turned up stated she began to feel hot temp 95.5 increased 02 [oxygen] to 2L [liters] "couldn't catch my breath," pt [patient] then fell into [Staff E] arms."

At 4:57 PM the "Cardio-Pulmonary Resuscitation" document showed, "no pulse pt [patient] asystole [cessation of electrical and mechanical activity of the heart] compressions started." Three hours and 17 minutes after she was discharge from the ED.

At 5:20 PM the "Cardio-Pulmonary Resuscitation" document showed, "Pt [Patient 17] intubated (tube placed in the windpipe when you can't breathe on your own) ..."

At 5:54 PM the "Cardio-Pulmonary Resuscitation" showed, " Staff G, MD called the code (life saving measures ended and death pronounced)."

Review of an "ED Provider Note" dated 06/06/23 at 1:05 AM, showed Staff G, MD documented, "It was evident upon first evaluation the patient will need to be admitted this time as she is subjectively worse than I saw her several hours before. Despite her initial tachypnea (fast breathing) I thought it would be reasonable to give her some DuoNebs (used to treat and prevent wheezing and shortness of breath) get a Venous Blood Gas (VBG) and decide if she would need BiPAP (non-invasive machine to help patient breathe) did not think she needed this intervention immediately. Felt like she would get a more broad work-up including EKG (electrocardiogram) lactate and blood work. Unfortunately she appeared to go into respiratory distress and failure and lost pulses very quickly into her ED course without much warning..." ED Testing: Of note patient was intubated for airway protection and respiratory failure there was good color change direct visualization fogging however at some point to must of dislodged as there is no longer color change or good oxygenation she was later intubated by respiratory therapist. Despite extensive resuscitation of time she never had meaningful ROSC (Return of Spontaneous Circulation) for any period of time and resuscitation efforts were terminated ..."

During an interview on 06/13/23 at 2:35 PM with Staff E, RN stated, " ...[Patient 17] had come in earlier in the day and was diagnosed with COPD exacerbation and pneumonia, the physician ordered a breathing treatment, antibiotic and prednisone then [Patient 17] was discharged home. [Patient 17] came back a few hours later struggling to breathe, patient was taken straight to room. [Patient 17] looked like she was trying hard to breath. I didn't listen to her lungs because she was in tripod position still talking then stopped mid-sentence and I noticed she was in distress I yelled for help and the code started ..."

During an interview on 06/14/23 at 9:07 AM, Staff G, MD stated that Patient 17 had COPD exacerbation with pneumonia that improved with duo-nebs, steroids, and antibiotics. Staff G went on to state that if Patient 17 feels that she had good social support, buys a pulse oximeter and feels better she can go home. Patient 17 later returned walked in looking more short of breath, labs were ordered and administered duo-nebs then Patient 17 went into cardiac arrest.

Based on record review, document review and interview the Hospital failed to provide stabilizing treatment for 2 of 20 patients (Patient 1 and Patient 17) who presented to the emergency department seeking emergency medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

Review of policy titled "EMTALA (Emergency Medical Treatment and Active Labor Act)" revised 01/20 showed " ... Stabilization:
A patient found to have an emergency medical condition shall be provided with stabilizing treatment within McPherson Hospital's capabilities, as follows:

1. Physician Evaluation. The patient's emergency medical condition shall be evaluated promptly by physician.

2. Stabilizing Treatment. If the physician determines an emergency condition, McPherson Hospital shall initiate necessary stabilizing treatment.

A. Stabilizing treatment consists of providing medically appropriate treatment within the capabilities of the McPherson Hospital medical staff and emergency department (including those ancillary services routinely available to the emergency department) necessary to assure that no material deterioration of the patient's condition is likely to result from, or occur during, the transfer or discharge of the patient ...
... C. If patient's condition has been stabilized. If, in the professional judgment of a physician, the patient's emergency medical condition has been stabilized, as defined above, the physician shall fully and clearly document the basis for this determination in the medical record.
i. The patient or his Representative may then be interviewed by McPherson Hospital personnel regarding financial arrangements to pay for the medical care that has been rendered or that may be sought.
ii. The patient may be referred for further non-emergency medical treatment either through the McPherson Hospital facilities, through a private physician or through appropriate health care facilities or at any other facility and/or the patient may be discharged.

D. If Patient's condition is Unstable: If the patient's condition remains unstable, stabilizing treatment shall continue to be provided within the capabilities of the emergency department. The patient may not be discharged, and if a decision is made to transfer an unstabilized patient, the transfer must be in accordance with the following procedures on TRANSFERS OF UNSTABILIZED PATIENTS..."

Patient 1

Review of Patient 1, medical record showed he presented to the ED on 12/23/22 at 10:12 PM via private vehicle with his wife with a chief complaint was dizziness for two weeks and slurred speech for two days. His wife states the slurred speech started this afternoon. Patient 1 past medical history included high blood pressure (force of blood is against the artery walls is too high), high cholesterol (high levels of fats in the blood), anxiety (feeling of worry and nervousness) and coronary artery disease (damage or disease in the heart's major blood vessels). Patient 1 was triaged at an Emergency Severity Index (ESI) 3 (stable and should be seen urgently).

Review of the "History" [History of Present Illness] showed " ...The patient is being seen for an acute stroke. The history is obtained from the patient and the patient spouse. Patient is 78-year-old male that presents with lightheadness [sic] present over the last two weeks. He states that yesterday started to notice some slurred speech. His wife noticed slurred speech today ..."

The "Physical Exam" showed, " ...Cranial nerves II-XII intact (A fiber tract emerging from the brain the trained examiner can localize lesions when abnormalities are found), sensation normal in all extremities, strength normal all extremities, patient speech does appear slightly slurred, but patient speaks with a stutter and without a baseline of his speech is difficult for me to tell definitively ..."

Review of the "Plan" showed, "Patient was discharged home. Offered patient admission to the hospital but I could not guarantee that standard work-up for stroke such as MRI (Magnetic Resonance Imaging - a non-invasive imaging technology that produces three dimensional detailed anatomical images), echocardiogram (a scan used to look at the heart and nearby blood vessels), and ultrasound of the carotids (arteries that supply blood and oxygen to the brain) would be available this weekend. We agreed that the patient would contact [Staff P, MD] patients primary care provider, and discuss getting his work-up done as an outpatient. Patient to return to the emergency department for any neurological changes. Patient was given a full aspirin prior to discharge."

Review of a document titled "[The Hospital] Hospital NIH [National Institute of Health] Stroke Scale (scale made up of 11 different element that evaluate specifically ability. The score for each ability is a number between 0 and 4, 0 being normal functioning and 4 being completely impaired) ...Baseline ...Best Language: 0- No aphasia (language disorder that affects the person ability to communicate can occur suddenly after a stroke] " showed, " ...Best Language: Ask patient to describe picture, name items; 0 [points] No aphasia 1 [points] Mild to moderate aphasia, 2 [points] Severe aphasia 3 [points] Mute; 10. Dysarthria Ask patient to read several words 0 [points] Normal articulation, 1 [points] Mild to moderate slurring of words 2 [points] Near unintelligible or unable to speak, 9 [points] Intubated or other physical barrier ...."

Review of a note dated 12/23/22 at 10:15 PM, "Neurologic" by Staff I, RN, showed " ...National Institutes of Health Stroke Scale (NIHSS); Dysarthria (slurred or slow speech that can be difficult to understand): 0- Normal Speech ...NIHSS Total Score: 0; Notified Provider: 12/23/22 10:16 PM; Pts [Patient] wife reports pt has "slurred speech", Slurred speech not noted during assessment but RN (Registered Nurse) notes pt seems to stammer or elongate pronunciation of the first letter of some words."

The medical record showed Patient 1 discharged on 12/24/22 at 12:10 AM with a disposition of home or self-care with dismissal instructions for Slurred Speech follow up with primary care physician.

Hospital staff failed to ensure Patient 1 was stabilized appropriately based on the EMTALA (Emergency Medical Treatment and Active Labor Act) Policy that showed stabilizing treatment consists of providing medically appropriate treatment within the capabilities of the McPherson Hospital medical staff and emergency department (including those ancillary services routinely available to the emergency department) necessary to assure that no material deterioration of the patient's condition is likely to result from, or occur during, the transfer or discharge of the patient.

Review of Patient 1's medical record MRA (procedure that uses radio waves and a powerful magnet linked to a computer to create detailed pictures of the blood vessels and blood flow inside the body) and MRI was completed on 12/27/22 at 11:57 AM approximately 83 hours post discharge from the ED. The Carotid Ultrasound was done on 12/28/22 at 2:58 PM approximately 110 hours post discharge delaying identification and treatment of an emergency medical condition.

During interview 06/12/23 at 10:00 AM with Staff A, Chief Operating Officer, (COO) states "MRI can be called in after-hours but they are not on call."

During an interview on 06/13/23 at 9:40 AM, Family Member 1 (F1), Patient 1's spouse, stated, " ...By 10:00 PM that night he was not speaking right and slurring his speech and getting worse and he always has correct pronunciation ... We told them the exact time frame when it started. They told us that they could admit him. The doctor told him that since it was Christmas that he would have to wait for MRI (magnetic resonance imaging), so my husband decided to go home ..."

During an interview on 06/13/23 at 3:30 PM, Staff F, Doctor of Medicine (MD), stated, " ...If the patient is out of the stroke window and the CT scan of the head is negative, we would give an aspirin, and we would admit to hospital if it's a first-time stroke for an ultrasound of carotids and echocardiogram (ultrasound of the heart) if they don't meet the transfer requirements ... If I tell a patient that they would need to be admitted and they refused I would have them sign out Against Medical Advice (AMA)."

During an interview on 06/14/23 at 8:40 AM, Staff M, RN, Executive Director of Nursing, stated, " ...The NIH the provider is supposed to do the NIH scale, but the nurse can also NIH scale..."

During an interview on 06/14/23 at 11:50 AM, Staff A, COO, stated " ...We do not require the NIH education for nurses since we are not a stroke center..."

During an interview on 06/14/23 at 2:17 PM with Staff O, Executive Secretary, stated " ...The Physicians don't have NIH education ..."

Review of Patient 1's medical record "Clinic Intake" [office notes] Stroke Follow up dated 12/29/22 at 2:59 PM " ...Discussed MRI findings and MRA [completed on 12/27/22 at above named hospital] findings showing the area in the cerebellum (stroke that reduces oxygen delivery causes motor and balance control) and right basilar artery occlusion (a stroke that can cause dizziness, headaches and speech especially dysarthria and difficulty articulating words) which is not amenable to any kind of treatment such as stenting (opens a clogged artery) etc. ..."


Patient 17

Review of Patient 17's medical record showed a 74-year-old female presented to the Emergency Department (ED) on 06/05/23 at 12:28 PM with a chief complaint was shortness of breath. Patient 17's past medical history included Chronic Obstructive Pulmonary Disease (COPD) (respiratory symptoms like progressive breathlessness and cough), Hypertension (elevated blood pressure), Hyperlipidemia (high levels of fats in the blood), and Asthma (airway inflammation). Patient 17 was triaged at an Emergency Severity Index (ESI) 3 (stable and should be seen urgently).

Patient 17's "History" [History of Present Illness]" showed, "The patient is being seen for dyspnea (shortness of breath). The history is obtained from the patient, the patient's family and 74-year-old female states that she started to become short of breath last night worse today. She reports a cough of dark brown and yellow sputum for the past week and a half family and patient conflicted on how new this is or how different is from her baseline she says that it is at her baseline family says it is perhaps of increased frequency. There is [sic] been no sick contacts. She has tried a breathing treatment about 1 hour prior to arrival. She denies other associated signs and symptoms. She is not on oxygen at home. Onset was (sic) patient continues to smoke has known history of COPD."

The physical exam dated 06/05/23 at 12:46 PM showed Staff G, MD, documented ... "Thorax and Lungs" Patient has end expiratory wheezes (continuous lung sound with a musical quality heard during expiration) and prolonged expiratory phase (respiratory muscles normally relax during exhalation) in all lung fields there is no rhonchi (low-pitched rattling lung sounds) appreciated. Cardiovascular Regular rate and rhythm, no murmurs, gallops or rubs, regular rate and rhythm, S1 and S2 (heart sounds) normal, no murmurs, gallops or rubs ..."

Review of a document dated 06/05/23 at 12:44 PM titled, "Vital Signs" showed Staff E, RN documented, " ...Temperature: 96.5 F (35.8 C) Temporal (normal Temperature 98.6); Pulse: 105 bpm (beats per minute) (normal 80-100 bpm); Pulse Ox 02 Saturation: 86 % (The amount of oxygen circulating in your blood, normal between 95% and 100%); Respiration: 22 breaths/min (normal 12-20 breaths/min.) ; Blood Pressure (BP): 131/77 Sitting (normal BP less than 120/80), R Arm;..."

Review of a document dated 06/05/23 at 12:51 PM titled, "ED Nursing Documentation Physical Assessment Respiratory" showed Staff E, RN documented, " ...Airway Clearance: Patent; Breathing Pattern: Labored, Short of breath Cough: Barking, Hacking, Dry; Left Lung Sounds: Rhonchi; Right Lung Sounds: Rhonchi ..."

Review of "Plan" dated 06/05/23 at 1:33 PM showed Staff G, MD documented, "Per EMTALA, this patient was given a medical screening exam and the condition was (sic) did not have access to vitals prior to examining the patient who is (sic) vital signs seem to improve my (sic) arrival. I told the patient there is plenty of clinical data to recommend blood work and consideration for admission. She would prefer to go home she lives 5 minutes from home and has good social contact she will buy a pulse oximeter and return if worse. I considered sepsis after reviewing her initial vital signs but I feel she is clinically improving and a reasonable outpatient candidate for both pneumonia and COPD exacerbation with close PCP (Primary Care Provider) follow-up and good return precautions."

The medical record showed Patient 17 discharged on 06/05/23 at 1:40 PM with disposition of home or self-care.
Prior to discharge on 06/05/23 at 1:40 PM, the hospital staff failed to include a reassessment of vital signs that showed Patient 17 had a documented Heart Rate <100, Respiration rate <20, and/or Oxygen Saturation (The amount of oxygen circulating in your blood) between 95% and 100%) or a functional test such as an ambulatory oxygen saturation evaluation for stability after presenting with "Bilateral pneumonia with acute on chronic pulmonary obstructive disease with acute exacerbation moderate, nicotine dependence."

Hospital staff failed to ensure Patient 17 was stabilized appropriately based on the EMTALA (Emergency Medical Treatment and Active Labor Act) Policy that showed stabilizing treatment consists of providing medically appropriate treatment within the capabilities of the McPherson Hospital medical staff and emergency department (including those ancillary services routinely available to the emergency department) necessary to assure that no material deterioration of the patient's condition is likely to result from, or occur during, the transfer or discharge of the patient.

Patient 17's medical record also failed to show Patient 17 left Against Medical Advice (AMA) after being advised by the physician the need for admittance to the hospital.

During an interview on 06/14/23 at 9:07 AM, Staff G, MD stated that if a patient does not want to be admitted, I would verbally tell them and document all the treatments and risks of leaving and have them sign out AMA.

Review of Patient 17's medical record dated 06/05/23 at 4:33 PM showed Patient 17 returned to the Emergency Department with complaint of, "I can't breath [sic] again." Two hours and 53 minutes from discharge.

Review of a document in Patient 17's record dated 06/05/23 at 4:48 PM titled, "Cardio-Pulmonary Resuscitation" showed, "Pt [Patient 17] in tripod position (sitting or standing leaning forward supporting upper body with hands or knees due to respiratory distress) saying she can't breathe requested 02 be turned up stated she began to feel hot temp 95.5 increased 02 [oxygen] to 2L [liters] "couldn't catch my breath," pt [patient] then fell into [Staff E] arms."

At 4:57 PM the "Cardio-Pulmonary Resuscitation" document showed, "no pulse pt [patient] asystole [cessation of electrical and mechanical activity of the heart] compressions started." Three hours and 17 minutes after she was discharge from the ED.

At 5:20 PM the "Cardio-Pulmonary Resuscitation" document showed, "Pt [Patient 17] intubated (tube placed in the windpipe when you can't breath on your own)..."

At 5:54 PM the "Cardio-Pulmonary Resuscitation" showed, " Staff G, MD called the code (life saving measures ended and death pronounced)."

Review of an "ED Provider Note" dated 06/06/23 at 1:05 AM, showed Staff G, MD documented, "It was evident upon first evaluation the patient will need to be admitted this time as she is subjectively worse than I saw her several hours before. Despite her initial tachypnea I thought it would be reasonable to give her some DuoNebs (used to treat and prevent wheezing and shortness of breath) get a Venous Blood Gas (VBG) and decide if she would need BiPAP (non-invasive machine to help patient breathe) did not think she needed this intervention immediately. Felt like she would get a more broad work-up including EKG (electrocardiogram) lactate and blood work. Unfortunately she appeared to go into respiratory distress and failure and lost pulses very quickly into her ED course without much warning..." ED Testing: Of note patient was intubated for airway protection and respiratory failure there was good color change direct visualization fogging however at some point to must of dislodged as there is no longer color change or good oxygenation she was later intubated by respiratory therapist. Despite extensive resuscitation of time she never had meaningful ROSC (Return of Spontaneous Circulation) for any period of time and resuscitation efforts were terminated ..."

During an interview on 06/13/23 at 2:35 PM with Staff E, RN stated, " ...[Patient 17] had come in earlier in the day and was diagnosed with COPD exacerbation and pneumonia, the physician ordered a breathing treatment, antibiotic and prednisone then [Patient 17] was discharged home. [Patient 17] came back a few hours later struggling to breathe, patient was taken straight to room. [Patient 17] looked like she was trying hard to breath. I didn't listen to her lungs because she was in tripod position still talking then stopped mid-sentence and I noticed she was in distress I yelled for help and the code started ..."

During an interview on 06/14/23 at 9:07 AM, Staff G, MD stated that Patient 17 had COPD exacerbation with pneumonia that improved with duo-nebs, steroids, and antibiotics. Staff G went on to state that if Patient 17 feels that she had good social support, buys a pulse oximeter and feels better she can go home. Patient 17 later returned walked in looking more short of breath, labs were ordered and administered duo-nebs then Patient 17 went into cardiac arrest.