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MUSCOGEE (CREEK) NATION MEDICAL CENTER 1401 MORRIS DRIVE OKMULGEE, OK 74447 Dec. 20, 2017
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on record review and interviews , the hospital failed to enter an individual (Patient #23) who presented to the emergency department by emergency medical services requesting medical attention for possible stroke into the central log.

This failed practice resulted in the hospital's inability to track all individuals presenting to the ED seeking emergency medical attention and ensure appropriate care was provided as defined by EMTALA regulations.

Findings:

A review of the Okmulgee County Emergency Medical Service document titled, "Run Report Narrative" and "Run Report" showed on 11/09/17, Patient #23 was taken to the hospital's ED at 1:35 pm.

A review of the hospital document titled, "ED Activity Log" showed ED patients who were admitted , transferred, discharged , left against medical advice, and left without being seen. On 11/09/17, Patient # 23 was not entered on the log.

A review of hospital policy titled, "EMTALA Policy (03/16)" provided no guidance regarding the ED's central log.

A review of hospital document titled, "Medical Staff Bylaws (07/11)" provided no guidance regarding the ED's central log.

On 12/20/17 at 8:00 am, EMT B stated he/she brought Patient #23 to the hospital's ED on 11/09/17.

On 12/18/17 at 11:48 am, Staff C stated on 11/09/17, the medics brought Patient #23 to the hospital's ED and were stopped by Staff D at the nurses' station. Staff C stated the EMS run sheet on 11/09/17 documented the medics arrived at the hospital at 1:35 pm and were back in the truck with the patient at 1:38 pm.

On 12/20/17 at 2:23 pm, Staff F stated he/she remembered Staff D talked to the EMS personnel on 11/09/17 regarding Patient #23. Staff F stated he/she believed Patient #23 was in ED, but was unable to remember exactly where the patient was located. Staff F stated he/she did not remember if the patient was in the EMS truck or not. Staff D stated everyone checked in or registered, the ED would be entered in the electronic ED log, including patients who arrive by ambulance.

On 12/19/17 at 9:21 am, Staff D stated the hospital and ED providers did not turn away any ambulance with a patient presenting for medical treatment. Staff D stated he/she had a vague awareness of the events of 11/09/17.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to provide a medical screening exam (MSE) for a patient (Patient #23) who presented to the hospital's ED by emergency medical services requesting medical attention for possible stroke..

This failed practice had potential to result in an emergency medical condition to be undetermined and go untreated.

Findings:

A review of the Emergency Medical Service (EMS) document titled, "Run Report Narrative" and "Run Report" showed on 11/09/17, Patient #23 was taken to the hospital's ED at 1:35 pm and returned to the EMS truck at 1:38 pm.

A review of hospital policy titled, "EMTALA Policy (03/16)" documented any individuals presenting to the hospital ED would receive an appropriate MSE by a qualified physician.

A review of hospital document titled, "Medical Staff Bylaws (07/11)" contained no information regarding EMTALA. On 12/20/17 at 3:00 pm, Staff A, COO, stated the physicians' had policies for EMTALA guidance and provided a document titled, "Muscogee (Creek) Nation Medical Center Medical Screening Examination". This MSE policy had no effective date or evidence of Governing Body approval. The MSE policy documented all patients presenting to the ED would receive a MSE by a physician to determine if an emergency medical condition existed, and designated the requirements of the MSE, such as vital signs, a focused physical assessment and other assessments based on the reasonable medical judgement of the ED physician. The MSE policy documented stroke-like symptoms were to be included in conditions that should always be treated as if an EMC exists.

A review of Patient #23 Skilled Nursing Facility (SNF) medical record showed the following:
*[AGE] year old female with recent history of left hemispheric stroke.
*admitted to the SNF unit for comprehensive rehabilitation including physical and occupational therapy.
*Between 11/07/17 -11/08/17, Patient #23 began to experience episodes of headaches, chest pains, transient elevations in blood pressure and vision loss.
*A CT was ordered on [DATE] by Patient #23's SNF's attending physician.
*On 11/09/17, CT scan results were received identifying a new area of infarction.
*On 11/09/17, Patient #23 continued to experience nausea/vomiting, severe headache, hypertension and vision loss.
*On 11/09/17 at 12:37 pm, Patient #23's attending physician at the SNF placed an order to transfer patient to the hospital as soon as possible and notified SNF nursing staff.

A review of a sample of 10 (Patient #7, 11, 12, 15, 16, 17, 18, 20, 21 and 22) of 22 ED medical records showed patients who presented with signs and symptoms suggestive of stroke received an MSE by a qualified physician after arrival in the ED. Six (Patient #7, 11, 15, 16, 17, and 22) of the 10 patients who presented with signs of stroke arrived to the ED by private vehicle and four (Patient #12, 18, 20 and 21) of the 10 arrived to the ED by EMS.

On 12/20/17 at 9:20 am, surveyors in the ED observed Okmulgee County EMTs arrive at the nurses' station in the ED with a possible stroke patient. Patient was a [AGE] year old female who presented with altered mental status and confusion who was last seen normal 2 days prior to arrival. MSE was performed by a qualified physician. Diagnostic work-up including CT scan of head, laboratory studies, EKG and Chest x-ray were initiated.

On 12/20/17 at 8:00 am, EMT B stated on 11/09/17 he/she responded to a call to pick up Patient #23 from a Skilled Nursing Facility (SNF) and was instructed by the SNF staff to transport Patient #23 to the hospital. EMT B described Patient #23 as having right-sided weakness and facial droop (using the Cincinnati Stroke Scale). EMT B stated an unidentified nursing staff at the SNF reported Patient #23 had a CT scan which showed a possible stroke, and needed to go to the hospital for magnetic resonance imaging (MRI). EMT B reported he/she prepared the patient for transport to the closest hospital emergency department (ED) per state emergency protocols which was MCNMC.

On 12/20/17 at 8:00 am, EMT B stated during transport, he/she called hospital by phone to notify them of incoming possible stroke patient. EMT B stated he/she was initially urged by an unidentified female nurse to transport the patient directly to a facility 50 minutes away. EMT B stated when he/she questioned nurse regarding need for transport to closest facility, the nurse accepted receipt of Patient #23. EMT B stated he/she called the hospital a second time to confirm acceptance of the Patient #23, and spoke to a male nurse (identified as Staff F), who stated the hospital had accepted the Patient #23 over the phone, and the hospital could not divert the patient to another facility.

On 12/20/17 at 8:00 am, EMT B stated when he/she brought the patient into the hospital's ED, Staff D (physician) was waiting at the nurse's station and stated "Why did you bring her here? EMT B stated Staff D stated the patient needed to go to another facility (name omitted-50 minutes away). EMT B stated there were multiple nursing staff watching the scene and heard discussion between he/she and the other EMT. EMT B stated Staff D did not perform any type of assessment, exam or provide treatment to the patient.

On 12/18/17 at 11:48 am, Staff C stated on 11/09/17, the medics brought Patient #23 to the hospital's ED and were stopped by Staff D (a physician) at the nurses' station. Staff C stated according to the EMS run sheet on 11/09/17, the medics arrived at the hospital at 1:35 pm and were back in the truck with the patient at 1:38 pm.

On 12/20/17 at 2:23 pm, Staff F stated he/she remembered Staff D (physician) talked to the EMS personnel on 11/09/17 regarding Patient #23. Staff F stated he/she believed the Patient #23 was in ED, but was unable to remember exactly where the patient was located.

On 12/19/17 at 9:21 am, Staff D stated the hospital and ED providers did not turn away any ambulance with a patient presenting for medical treatment. She/he stated the provider would perform an exam and provide any necessary stabilizing treatment. Staff D stated she/he had a vague awareness of the events of 11/09/17. He/she stated "if this was the same case [he/she] was thinking of", the "paramedics" (EMTs) called and notified the ED, they were bringing in a patient who was having stroke symptoms. When the "paramedics" (EMTs) would receive a call for a patient with a potential stroke, EMS would divert the patient to the closest facility for care. Staff D stated if EMS knew the patient was having a stroke they would decide what care was needed. Staff D stated many times emergency medical services (EMS) would contact the ED for notification for use of the helipad only for patient transfer and EMS did not bring the patient to the ED per Okmulgee County Protocols. Staff D stated he/she did not recall if the EMTs transferred the Patient #23 to the air ambulance at the hospital's helipad on 11/09/17.

On 12/19/17 at 9:21 am, Staff D stated frequently complaints of altered mental status might be symptoms of stroke and the hospital did not have neurology services, therefore the patient with potential neurology needs would be transferred to a facility able to provide a higher level of care. Staff D stated for these patients, the ED physician would still perform a medical screening exam (MSE) and provide stabilizing treatment.