HospitalInspections.org

Based on document review and interview, it was determined for 1 of 9 (Pt #1) patients records reviewed, the Hospital failed to ensure potential stroke care was provided, in accordance with its policy to prevent the potential for deterioration in patient status. This has the potential to affect all patients who receive care by the Emergency Department (ED) with an average monthly census of 1050 visits.

Findings include:

1. The policy titled "Stroke Alert Protocol" (effective by the hospital May 2019) was reviewed on 10/28/2021 at approximately 11:00 AM. The policy indicated, "Procedure: 1. All patients with suspected acute stroke should be triaged with priority, regardless of the severity of deficits in the Emergency Room ... 3. Physician assessment within 15 minutes of arrival to department. MD (Medical Doctor) orders Stroke Alert protocol, if warranted ... Implementation: 3. A stroke alert is called when a patient presents to the ER (Emergency Room)with stroke symptoms or with acute neurologic changes that begin within 6 hours prior to arrival. Stroke symptoms include: a. Sudden acute onset of numbness or weakness of face, arm or leg-especially on one side of the body ... Protocol: 1. All patients with suspected acute stroke should be triaged with priority, regardless of the severity of deficits in Emergency Room. 3. Physician assessment within 15 minutes of arrival to department. MD orders Stroke Alert protocol, if warranted ... Implementation: 3. A stroke alert is called when a patient presents to the ER with stroke symptoms or with acute neurologic changes that begin within 6 hours prior to arrival. Stroke symptoms include: a. Sudden acute onset of numbness or weakness of face, arm or let-especially on one side of the body ... Protocol: 1. All patients with suspected acute stroke should be triaged with priority, regardless of the severity of deficits in Emergency Room."

2. Pt #1 Date of Service: 10/08/2021
Chief Complaint: Pregnancy less than 20 weeks. Pt #1's record was reviewed throughout 10/28/21.
ER triage nursing documentation (E#5) indicated Pt #1 arrived at the ER on 10/08/21 at 9:49 AM with the chief complaint of "pregnancy issues < (less than 20 wks (weeks)." Pt #1 was taken to ER room 5. Under "Patient Narrative" it indicated Pt #1's estimated due date was 4/28/22 and that she was approximately 11 weeks pregnant. It further indicated, "This am (morning) woke and states that she just didn't "feel right". Felt that left side of mouth was drooping. No drooping noted on arrival speech clear." Blood pressure was 152/90; pulse was 105, respirations 20, temperature 97.8, pulse oximeter was 96% on room air, and Glasglow Coma Scale was 15." The neurological exam (eye movement, hand grip, leg strength, level of consciousness, orientation, pupillary response, and speech) were within normal limits. The Stroke Alert Protocol alerts were not made.
ER physician (MD#1) documentation indicated Pt #1 was assessed at 10:30 AM (41 minutes after arrival). MD#1's ER note was transcribed by MD#1 to E#2 on 10/28/21 at 12:00 PM, due to inability to read the note. The transcription indicated Pt #1's chief complaint was "numbness on face/hands. Pt with hx (history) of feeling numbness on left side of face involving forehead and numbness on both hands. Started at rest at 9 AM and lasted for about 10 minutes on the face and improving numbness on both hands. No weakness, no headache, no shortness of breath. Pt is currently 11 weeks pregnant ... Alert and oriented times three in no distress ... all labs (Complete blood count and comprehensive metabolic panel) unremarkable." At 11:15 AM, "pt felt better no more numbness on the face and hands, vs (vital signs) stable, alert oriented times 3." Pt #1 was discharged with the diagnosis of Facial Parathesias.

3. On 10/28/21 at approximately 12:10 PM, an interview was conducted with the Director of Quality (E#1) and the Critical Care Coordinator (E#2). Both had reviewed Pt #1's record. E#2 stated, "Yes, the stroke alert notification of a possible stroke should have been done and they weren't (by the nurse) and the patient should have been seen by the doctor within 15 minutes and they weren't."

4. On 10/28/21 at approximately 12:20 PM, an interview was conducted with the Director of Critical Care, ER, and ICU (E#3). E#3 stated having reviewed Pt #1's record and that the nurse should have implemented the stroke protocol and the physician should have seen the patient within 15 minutes and did not.

5. On 10/28/21 at approximately 12:45 PM, a phone interview was conducted with the Medical Director for ER (MD#2). MD#2 stated, "My review is that it was a TIA (transient ischemic attack) and required imaging (Computed Tomography)."

6. On 10/28/21 at approximately 1:55 PM, an interview was conducted with the ER physician who cared for Pt #1 (MD#1). MD#1 stated, "The bilateral symptoms (numbness of both hands) was the difference. If it was all unilateral, I would have done a CT. I have to balance the risks of a CT to the pregnancy and because (Pt #1's) symptoms were almost gone, I didn't feel the CT was necessary."

7. On 10/28/21 at approximately 2:05 PM, a phone interview was conducted with the ER Registered Nurse (RN- E#5) who cared for Pt #1. E#5 stated, "I just remember (Pt #1) came in and was pregnant and was having numbness on and off on left face and both hands... It didn't seem like it (Pt #1's symptoms) needed to have it (Stroke Protocol). (Pt #1's) blood pressure wasn't abnormally high, no weakness in hands, no speech difficulty, no vision issues that would trigger it (Stroke Protocol) and even the doctor didn't think it was necessary or he would have ordered it."

8. The HealthStream computer based learning documentation was reviewed and indicated E#5 completed the FAST-VAN (F-face droop, A- arm drift, S- speech, T-time, V- vision, A-aphasia, N- neglect) Stroke Education on 9/7/21 with 100% score. On page 4, the education indicated, "TIA- Transient Ischemic Attack ... temporary blockage of blood flow to the brain ... S&S (signs and symptoms) resolve in 24 hours ... Does not leave lasting damage ... TIA occurs before about 15% of all strokes ... 1/3 of TIA patients have a severe stroke within 1 year." On page 22, the education indicated, "Sudden acute onset of numbness/weakness (especially on one side) ..."