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Based on policy review, document review, medical record review, ambulance trip review, and interview, the hospital failed to ensure all patients presenting to the emergency department (ED) were provided an appropriate medical screening exam (MSE) within the hospitals capabilities for 1 of 20 (Patient #6) sampled patients to determine if an emergency medical condition existed.

The findings included:

1. Patient #6 was a 61 year old female who presented to Hospital #1 on 9/7/2022 at 3:12 PM with complaints of hypertension and weakness, and reported her home blood pressure was 219/70 prior to arrival. Patient #6 was triaged at 3:22 PM and determined to be an ESI (emergency severity index ) Level 3. The ED was full therefore Patient #6 was seated in the ED waiting room. There were no subsequent assessments and Patient #6 eloped at 4:16 PM without a medical screening exam. Patient #6 returned to the ED for a second visit on 9/7/2022 at 5:36 PM with similar complaints. Patient #6 was triaged at 5:43 PM, and again assigned an ESI Level 3 and seated in the ED waiting room, because no ED beds were available.

In an interview, Patient #6's spouse stated he repeatedly told the person at the ED Registration area he thought Patient #6 was having a stroke and needed to be seen by a provider. Patient #6's spouse further stated he left Hospital #1 and transported her to Hospital #2 because he was "afraid she was going to die."

Patient #6 presented to Hospital #2 on the night of 9/7/2022 and was triaged at 10:35 PM. Based on reports of "left sided weakness since yesterday," the Triage nurse assigned a Level 2 ESI. The MSE was initiated at 10:37 PM including labs, Electrocardiogram and Computerized Tomography. Patient #6 was determined to have a possible Cerebrovascular accident (stroke) and transferred to a higher level of care [Hospital #1 where she had previously sought treatment two separate times on 9/7/2022] on 9/8/2022. Patient #6 required inpatient hospitalization and was diagnosed with Ischemic Stroke and required Physical, Occupational and Speech therapies to address deficits related to her diagnoses. Patient #6 was discharged on 9/12/2022 to a skilled nursing facility for continued therapy to address the deficits resulting from her stroke.

Refer to A-2406.

Based on policy review, document review, medical record review, ambulance report and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking treatment were provided an appropriate and on-going medical screening exam (MSE), monitoring and treatment for 1 of 20 (Patient #6) sampled patients.

The findings included:

1. Review of the hospital policy "EMTALA [Emergency Medical Treatment and Labor Act] most recently revised 5/19/2020 revealed, "...To ensure patients presenting to [named Hospital #1] seeking emergency treatment are cared for in a timely fashion in accordance with good medical practices and, if applicable, in compliance with EMTALA. EMTALA obligations may arise whenever an individual comes to the hospital, to the hospital's campus, or to an off-campus DED [dedicated emergency department] of the hospital and...the individual requests an examination or treatment for an emergency medical condition orb) if a prudent layperson observer would believe that the individual may be suffering from an emergency medical condition. EMTALA obligations include: 1. To provide an appropriate medical screening exam (MSE)...It is important that all professionals in the DED provide clear and complete documentation of all assessments, treatments, and discussions pertinent to patient evaluation, care...Presentation to DED for Care and Medical Screening Examination (MSE)...Any individual who comes to the DED of [named Hospital #1] shall undergo a MSE to determine whether that individual is experiencing an "emergency medical condition" ("EMC")...Generally, an EMC is one manifesting such symptoms (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to a bodily organ or function...An MSE in the DED may be performed by a physician, a nurse practitioner and/or a physician's assistant...The MSE shall include those ancillary services routinely available to, although not necessarily located in, the DED. The MSE must be similar for all individuals presenting with similar symptoms, without regard to diagnosis, financial status, race, age, color, national origin, handicap or sexual orientation...If a patient withdraws his/her request for examination or treatment, an appropriately trained individual from the DED staff (i.e. triage nurse or designated RN) will discuss the medical issues related to such "voluntary withdrawal." In the discussion, the DED staff member will: Offer the patient an MSE as may be required to identify an EMC...Inform the patient of the benefits of the examination, and of the risks of withdrawal prior to receiving the examination; and Ask the patient to sign a 'Withdrawal of Request for Emergency Care' Form...which shall be completed by the DED staff member. If the patient refuses to sign the form, a description of risks discussed and the examination that was refused shall be documented...If a patient leaves the hospital prior to receiving a MSE without notifying personnel, this departure should be documented. The documentation must reflect that the patient had been at the hospital and the time that the patient was discovered to have left the premises. Triage notes and additional records, if any, must be retained..."

Review of the hospital policy "Triage Guidelines/Procedure" most recently revised 5/19/2020, revealed, "Triage is rapid, direct patient assessment resulting in assignment of an acuity level for each patient arriving in the department...The triage assessment does not constitute a medical screening exam....Upon presentation to the ED, every patient should be assessed and assigned a level of acuity using ESI [Emergency Severity Index a five level triage categorization system]...Level 2: Emergent Definition: The patient presents with a condition posing a threat to life, limb, or function and requires rapid medical intervention...Neurological...high BP, lethargy...Acute alteration in level of consciousness, Sudden onset of speech deficits or motor weakness...Level 3: Urgent Definition: The patient presents with a condition that could progress to a serious problem requiring emergency intervention. The vital signs of a Triage Level 3 patient may or may not be outside normal limits (danger zone) and the presenting condition is anticipated to require the utilization of two or more resources..."

2. Review of a letter from The Joint Commission dated 8/15/2021 revealed Hospital #1 was designated as an Advanced Primary Stroke Center effective 8/12/2021 for the duration of 2 years.

3. Medical record review for Patient #6 revealed a 61 year old female who presented to Hospital #1's ED on 9/7/2022 at 3:12 PM via personal vehicle. Triage was initiated at 3:22 PM by Registered Nurse (RN) #2. RN #2 documented the chief complaint as hypertension (HTN) and weakness with Patient #6 reporting her home blood pressure (BP) of 219/70. Patient #6 reported to RN #2 "my brain is not working." RN #2 documented Patient #6 was able to answer all questions in triage and had a history of Type 2 Diabetes Mellitus,HTN and Chronic Kidney disease (CKD). Patient #6's vital signs were recorded as : BP- 157/67, Heart rate- 72 beats per minute, Respiratory rate 20 breathes per minute and Oxygen Saturation 96% using room air. RN #2 assigned Patient #6 an ESI level 3 and Patient #6 returned to the ED waiting room because no ED beds were available. Patient #6 did not receive a MSE. Patient #6 did not have any additional documented vital signs. Review of the "ED Departure Communication Tool" dated 9/7/2022 and timed 4:16 PM revealed Patient #6 eloped after triage. There was no documentation the nursing staff attempted to call Patient #6 for treatment/reassessment three (3) times before removing her from the ED system.

Patient #6 returned to Hospital #1's ED on 9/7/2022 at 5:36 PM via personal vehicle. Triage was initiated by RN #2 at 5:43 PM. RN #2 documented, Patient #6 returned to ED after leaving against medical advice (AMA) [patient #6 did not leave AMA- she did not receive an MSE on previous visit] with complaints of weakness and HTN. RN #2 documented Patient #6 was alert and oriented and able to answer all questions during triage. Patient #6's vital signs were recorded as : BP- 180/79, Heart rate- 75 beats per minute, Respiratory rate 20 breathes per minute and Oxygen Saturation 99% using room air. RN #2 assigned Patient #6 an ESI level 3 and Patient #6 returned to the ED waiting room because no ED beds were available. Patient #6 did not receive a MSE. Patient #6 did not have any additional vital signs or reassessments. Review of the "ED Departure Communication Tool" dated 9/7/2022 and timed 9:18 PM revealed Patient #6 eloped after triage. There was no documentation the nursing staff attempted to call Patient #6 for treatment/reassessment 3 times before removing her from the ED system.

4. Patient #6 presented to Hospital #2's ED on 9/7/2022 and Triage was initiated at 10:35 PM. with the chief complaint "...left sided weakness since yesterday am [morning] hx [history] HTN, smoker, renal disease.." Patient #6 vitals signs were BP- 178/76, Heart rate- 84 beats per minute, Respiratory rate 16 breathes per minute and Oxygen Saturation 94% using room air. Patient #6 was assigned an ESI level 2- Emergent by the Triage Nurse. The MSE was initiated at 10:37 PM and the ED Physician documented, "Patient presented to the emergency department with husband and another family member with concerns over confusion, abnormal speech, weakness and somnolence [drowsiness]...it appears that the absolute most recent time patient was seen somewhat normal would have been yesterday morning...She has had some waxing and waning levels of confusion as well as slurred speech and 'saying things that do not make sense' She has been weak in general but appeared to be a bit weaker on the left, leaning to that side an unable to support her weight to ambulate...NEURO: Appears to be weaker on the left, more prominent in the upper extremity than the lower. Questionable mild facial droop. Patient does seem to have some difficulty tracking finger movement to the right conversely. Very difficult to understand slurred speech..." Patient #6 Electrocardiogram results dated 9/7/2022 at 11:36 PM were documented as "Supraventricular Rhythm"[Irregular Heartbeat] Possible right Ventricular Hypertrophy [abnormal enlargement of the cardiac muscle surrounding the right ventricle] -Abnormal EKG" Computerized Tomography results dated 9/7/2022 at 11:31 PM revealed, "No acute intracranial process... small hematoma superior right parietal scalp..." Review of labs revealed the following abnormal results: Hemoglobin- 10.7 (low), Potassium-3.4 (low), Troponin- 102.5 (critically high indicating cardiac event), White Blood Cells- 11.8 (high) Creatinine- 5.1 (critically high related to chronic kidney disease diagnosis), Glucose- 177 (high). The ED physician documented he planned to discuss possible admission with a hospitalist at Hospital #1. On 9/8/2022 at 12:11 AM, the ED Physician documented, "Unfortunately patient can not be admitted to this facility for stroke work up as her symptoms may also be caused by uremia secondary to her worsening kidney function. Unfortunately, [named Hospital #1] does not have any beds available and will likely not until tomorrow morning. There are no beds available [named 4 different hospital systems within a 3 county radius capable of a higher level of care]. Patient #6 remained in Hospital #2 ED and was treated with medications and monitored until she could be transferred to Hospital #1 for further evaluation.

5. Patient #6 was transferred to Hospital #1 for a higher level of care via Emergency Medical Services (EMS) on 9/8/2022. The EMS trip report revealed the Primary diagnosis as "Stroke" with left sided weakness, confusion and abnormal labs. The EMS narrative revealed, "Dispatched to [named Hospital #2] for emergency transfer to [named Hospital #1] to find a 61 year old female alert to person and place only... Staff states Pt. [patient] has possibly had a stroke as well as having elevated troponin and kidney failure. She is being sent out to [named hospital #1] for Neurology...Transported emergency to [named Hospital #1] Pt requires ambulance due to needing cardiac hemodynamic and IV [intravenous] monitoring, as well as not being able to maintain seated position. Patient #6 arrived at Hospital #1 via EMS on 9/8/2022 at 3:22 PM with care transitioned to Hospital #1's staff at 3:28 PM.

6. Review of Patient #6's inpatient hospital records from Hospital #1 revealed Patient #6 was admitted on 9/8/2022 at 3:28 PM from Hospital #2 with altered mentation, recent falls and left sided weakness. On 9/8/2022 at 5:28 PM, a Magnetic Resonance Imaging (MRI) found Patient #6 had a small acute infarct involving the right corona radiata (Certain types of strokes can damage the corona radiata. This bundle of nerve fibers in the brain carries information between cells in the outermost layer of the brain [cerebral cortex] and those in the brain stem). Patient #6 was treated with Aspirin and high intensity statins while hospitalized. Patient #6's mentation and neuro deficits gradually improved, however Patient #6 required Physical Therapy, Occupational Therapy and Speech Language Pathology services during her hospitalization as a result of the CVA (stroke). Patient #6 was discharged from Hospital #1 on 9/12/2022 to a skilled nursing facility due to continued need for skilled therapy services.

7. In a telephone interview with Patient #6's spouse he stated he took his wife to Hospital #1 on 9/7/2022 at about 1:00 PM and they had to wait in the waiting room, so they left about 3:15 and then went back to the ED again at 4:00 PM. Patient #6's husband stated he told them "repeatedly" he thought Patient #6 was having a stroke, but the person at the registration desk stated, "I'm sorry you will have to wait your turn." Patient #6's husband was unable to provide the name or description of the individual who told them they would have to wait their turn. Patient #6's husband reported they left Hospital #1 because it was taking too long and he was afraid Patient #6 "was going to die". Patient #6's husband verified he transported Patient #6 to Hospital #2 in his personal car. Patient #6's husband reported the patient was treated at Hospital #2's emergency room on the night of 9/7/2022 and later transferred to Hospital #1 for additional care.

In an interview on 11/15/2022 at 1:25 PM, the Stroke Trauma Coordinator stated if there was a concern identified for a patient's vital signs, staff would seat them in the internal waiting area, just outside of Triage so staff could monitor patients if there was no available ED rooms. When asked how the decision was made to seat patients in the internal waiting area for monitoring, the Stroke Trauma Coordinator stated "The Triage nurse clinical judgement..."

In an interview on 9/15/2022 at 2:30 PM, the ED Nursing Manager stated there was no documentation that nursing staff called Patient #6 for care three (3) times before removing her from the system on either visit for 9/7/2022. The ED Nursing Manager stated there was not a policy for calling a patient 3 times, but it was hospital practice and should be documented in the medical record.

In a telephone interview on 11/16/2022 at 8:48 AM, RN #1 verified he was the second triage nurse working on 9/7/2022. When asked if he recalled Patient #6 he stated "I do because of the circumstances behind it..." RN #1 stated he did not perform triage for Patient #6 but he did remove her from the system when it was determined she had left the ED. RN #1 stated [named Hospital #2] called to inform Hospital #1's ED that Patient #6 had presented to Hospital #2's ED and could not be registered there until she was removed from Hospital #1's ED system. RN #1 clarified that Hospital #1 and #2 are owned by the same company and therefore their systems were linked. When asked where the nursing staff would have documented calling the patient back 3 times before removing her from the system, RN #1 stated, "Up until this time, I did not even know where to document that [in the medical record]." RN #1 stated the ED Nurse Manager had informed him where to document that information in the future. He further verified he did not know Patient #6 had left the premises until Hospital #2 staff called to report she was seeking care at their hospital.

In an interview on 11/16/2022 at 9:08 AM, RN #2 verified she was working as a Triage nurse on 9/7/2022 when Patient #6 presented for treatment at 3:12 PM. RN #2 stated she recalled Patient #6 reported she had hypertension but it had resolved at the time RN #2 took her vital signs during triage. When asked why the BP of 157/67 was not concerning, RN #2 stated due to Patient #6's chronic hypertension diagnosis. RN #2 stated Patient #6 was awake, alert and oriented and ambulated without assistance into the triage area. RN #2 stated based on her assessment patient #6 was assigned an ESI level 3 and seated in the waiting room. RN #2 stated she had no further interactions with Patient #6 on that ED visit and was not aware of the time Patient #6 eloped. RN #2 stated she did not recall any staff alerting her that Patient #6 or her family had expressed concerns for the long wait time or changes in Patient #6's status. RN #2 verified she also performed triage for Patient #6 when she returned to the ED on 9/7/2022 at 5:36 PM. RN #2 stated Patient #6 presented with the same complaints on the second ED visit. RN #2 stated Patient #6 was not exhibiting signs of a stroke and she was alert oriented and answered all the triage questions. RN #2 stated she was unable to recall if Patient #6 had any family present during triage. RN #2 stated based on her assessment patient #6 was again assigned an ESI level 3 and seated in the waiting room. RN #2 stated she had no further interactions with Patient #6 and she was unaware of the time Patient #6 eloped.

In a telephone interview on 11/16/2022 at 9:31 AM, the Greeter#1/Patient Care Technician, who was working on 9/7/2022 when Patient #6 presented seeking treatment, stated she did not recall Patient #6. Greeter #1 stated it was common for patients and families to voice concerns for long wait times and it was her practice to pass that information along to the Triage nurse or Charge Nurse. Greeter #1 again stated she did not recall Patient #6 since it had been several months.

In an interview on 11/16/2022 at 10:04 AM, the ED Nursing Manager stated based on the documentation of what Patient #6 presented with and the assessment, she was in agreement with RN #2's ESI level 3 assignment. The ED Manager stated, "I think she should have done a blood sugar check based on Patient #6's complaints of inability to think, but we have discussed that with [named RN #2].