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Based on interview and record review the facility failed to follow its policy & procedure (P&P) titled, "Stroke Alert and Acute Care Stroke Management: Emergency Department and Inpatient Units," for one patient (Patient 1), when Patient 1 was identified to have left-sided weakness, and a stroke alert was not called in a timely manner by Registered Nurse (RN) 1. This failure resulted in delayed identification and treatment of Patient 1's deteriorating (worsening) condition and the potential to result in Patient 1's death.

Findings:

During a review of Patient 1's "Emergency Room Note (ERN)," dated 3/13/25 at 2:19 p.m., the "ERN" indicated "70 year old male with past medical history significant for previous stroke 10/2021 and vascular dementia [a type of dementia caused by problems with the blood supply to the brain] presents to the Emergency Department accompanied by his [Family Member (FM)] sent by [Neurologist- doctor who specializes in brain and nerve function] for abnormal MRI [Magnetic Resonance Imaging - a kind of x-ray]. . .Symptoms of altered mental status [a change in a person's usual mental function, including changes in awareness and behavior], face numbness, and slurred speech. . .NEUROLOGICAL: Patient appears confused, nonsensical speech [speech that is difficult to understand] . . .Plan: "admit acute care w/in [within] hospital. . .Clinical impression: Acute cerebrovascular accident [CVA- also known as a stroke, is a medical condition characterized by the sudden interruption of blood flow to the brain, leading to the death of brain cells and potential neurological damage]."

During a review of Patient 1's "MRI of the Brain (MRI)," dated 3/13/25, the "MRI" indicated "HISTORY: Headaches, dizziness, right-sided numbness and weakness, right-sided vision loss x [for] 3 days. IMPRESSION 1. Proximal occlusion [blockage in the large blood vessels in the neck or base of the brain] of the left posterior [behind] cerebral artery [the blood vessels that supply oxygen and nutrients to the brain] resulting in ischemia [shortage of blood and oxygen supply] of most of the remaining left occipital [the visual processing center of the brain] and posterior medial [middle] temporal lobes [a section of the brain that is involved in processing hearing information, memory, and language] as well as portions of the left thalamus [part of the brain for sensory and motor information] and internal capsules [ two structures located within the brain for communicating sensory and motor information]. . .this case was discussed with the emergency room [sic] at 2:08 PM 3/13/25, and patient [Patient 1] was taken to the emergency room by radiology staff at 2:10 p.m."

During a review of Patient 1's "National Institutes of Health Stroke Scale (NIHSS- a tool used to quickly assess the severity of stroke in patients)," dated 3/13/25, the "NIHSS" indicated, "Level of consciousness: Alert, Orientation: Answers Nether Correctly, Responds to Commands: Performs both correctly, Visual fields Partial Hemianopia [a condition where there's a loss of vision in half of your visual field], Facial Movement Normal, Left Arm Motor Function No Drift, Right Arm Motor Function No Drift, Left Leg Motor Function No Drift, Limb Ataxia [poor muscle control] absent, Sensory Mild to moderate, Language Mild to moderate aphasia [loss of ability to understand or express speech, caused by brain damage], NIH Stroke Score 7 [The scale ranges from 0 to 42, with a higher score indicating greater neurological deficits. A score of 0 means there are no stroke symptoms, while a score of 21 or higher indicates a severe stroke. 0-4: Minor stroke or no stroke symptoms. 5-15: Moderate stroke. 16-20: Moderate to severe stroke. 21-42: Severe stroke] NIH Stroke Level: Moderate Stroke."

During an interview on 5/19/25 at 2:30 p.m. with RN 1, RN 1 stated signs and symptoms (s/s) of a stroke include arm weakness. RN 1 stated if a patient has any of these s/s RN 1 would call a rapid response [RRT- a specialized group of healthcare professionals, including nurses and respiratory therapists, who are trained to intervene quickly and prevent a patient's medical condition from deteriorating into a serious emergency], complete a neurological assessment (conditions that affect the brain), complete a physical assessment (checks your body to determine if you do or do not have a physical problem) and document the findings. RN 1 stated a RRT should have been called for Patient 1.

During a review of Patient 1's "Neurological Assessment (NA)," dated 3/19/25 at 5:00 p.m., the "NA" indicated, "Bilateral Leg -Strength Slight Weakness Left Arm- Strength Slight W Right arm -Strength Slight Weakness."

During a review of Patient 1's "NA," dated 3/19/25 at 9:00 p.m., the NA indicated, "Left Arm -Strength Flaccid. Right Arm-Strength Slight weakness. . .Facial Symmetry Left Side Droop. . .Stroke -New Onset Signs and Symptoms of Stroke Yes."

During a concurrent interview and record review on 5/20/25 at 3:03 p.m. with Director of Nursing (DON), Patient 1's "Nurse Note (NN)," dated 3/19/25 at 6:35 p.m. by RN 1 was reviewed. The NN indicated, "I [RN 1] was notified by patient's [Patient 1's] wife that patient was not moving left extremities. Upon assessment patient left extremities [arm and leg] appeared flaccid [loose and hanging-unable to move]." DON stated when Patient 1 was not moving his left arm and leg, RN 1 needed to call a stroke alert immediately. DON stated RN 1 needed to complete an assessment and notify the physician.

During a concurrent interview and record review on 5/20/25 at 3:30 p.m. with DON, Patient 1's "NN," dated 3/19/25 at 7:14 p.m. by RN 1 (approximately 39 minutes after COC was documented), the NN indicated, "Notified [medical doctor] that patient left upper and lower extremity were remaining flaccid, [medical doctor] to see patient at bedside." DON stated RN 1 needed to call a stroke alert before notifying the physician.

During a review of Patient 1's "Event Note (EN)," dated 3/20/25, the "EN" indicated, "At 7 PM a rapid response was called as the patient was noticed to have flaccid paralysis of the left upper extremity. . . He [Patient 1] was noticed that he can move all his right side of the body however noticed to have severe weakness on his left upper extremity, left lower extremity there is some movement however not against gravity. For that reason, a stroke alert was initiated and patient was sent to CT [Computed Tomography - a type of x-ray] scan for the brain and head and neck CT. . ."

During a concurrent interview and record review on 5/20/25 at 3:35 p.m. with RN 1, Patient 1's electronic medical record (EMR) was reviewed. RN 1 stated there was no documentation of interventions or physical assessment completed for Patient 1 after the notification of left sided upper and lower extremities remaining flaccid (3/19/25 at 6:35 p.m.) and before the physician was notified (3/19/25 at 7:14 p.m.). RN 1 stated a stroke alert should have been called as these are signs of a stroke, and the physician notified.

During a concurrent interview and record review on 5/21/25 at 8:55 a.m. with Stroke and Sepsis Coordinator (SSC), Patient 1's "NN," dated 3/19/25 at 6:35 p.m. and Patient 1's "NN," dated 3/19/25 at 7:14 p.m. were reviewed. The NN at 6:35 p.m. indicated Patient 1 was not moving the left extremities. The NN at 7:14 p.m. indicated RN 1 notified the Medical Doctor (MD) 2 of Patient 1's COC. SSC stated the 39-minute delay of notifying the MD was not appropriate. SSC stated RN 1 was expected to immediately call a stroke alert or immediately call the physician when Patient 1 had signs of stroke. SSC stated their policy is to activate a stroke alert within ten minutes of symptoms.

During a concurrent interview and record review on 5/21/25 at 9:05 a.m. with SSC, Patient 1's "NIHSS," dated 3/19/25 at 7:24 p.m. was reviewed. The NIHSS indicated, "Not Alert Obtunded [reduced level of alertness], Orientation Answers Neither Correctly, Responds to Commands Performs neither correctly, Visual fields Complete Hemianopia, Facial Movement Complete Paralysis, Left Arm Motor Function No Movement, Right Arm Motor Function No Drift, Left Leg Motor Function: No Effort Against Gravity, Limb Ataxia Present in one limb, Language Severe aphasia, NIH Stroke Score 23 [The scale ranges from 0 to 42, with a higher score indicating greater neurological deficits. A score of 0 means there are no stroke symptoms, while a score of 21 or higher indicates a severe stroke. 0-4: Minor stroke or no stroke symptoms. 5-15: Moderate stroke. 16-20: Moderate to severe stroke. 21-42: Severe stroke] NIH Stroke Level: Severe Stroke." SSC stated an increase of three or more points of the NIHSS score indicated a significant change in symptoms of stroke for Patient 1.

During an interview on 5/21/25 at 9:12 a.m. with Registered Nurse (RN) 2, RN 2 stated shift began at 6:45 p.m. and RN 2 received hand off report from RN 1 at Patient 1's bedside with FM. RN 2 stated FM said during report Patient 1 was having left-sided weakness and unable to move the left side earlier that day. RN 2 questioned RN 1 about Patient 1's COC and if MD had been notified. RN 2 stated RN 1 reported the MD had rounded on Patient 1 but was not sure if the MD was aware of the weakness to Patient 1's left side. RN 2 stated she instructed RN 1 to immediately call the MD. RN 2 stated MD came to Patient 1's bedside, completed a quick assessment and immediately called a stroke alert. RN 2 stated when Patient 1's COC was identified, interventions, including calling a rapid response should have been started immediately and the MD should have been notified.

During a review of Patient 1's "NN," dated 3/19/25 at 7:15 p.m. (by RN 2), the NN indicated, "report received from [RN 1]. New onset left sided weakness noted. LWK [last well know] at 3:18 p.m. [MD] called to bedside for change in neurological status by [RN 1]. 7:20 p.m. [MD] at bedside. Initiated stroke alert. RRT [rapid response team] called for stroke alert. 8:00 p.m. pt [Patient 1] send down to CT brain. . ."

During a review of the "Rapid Response Intervention (RRI)," dated 3/19/25 at 7:20 p.m. the RRI indicated, "The rapid response was called on 3/19/25 at 7:20 p.m. [approximately 45 minutes after Patient 1's symptoms of stroke]. . .Situation: acute change in conscious [being awake]; background: new onset left sided weakness; rapid response assessment: pt [Patient 1] with eyes closed, left side flaccid, non-verbal, does not follow commands, movement to right side-reaching out. . ."

During a review of Patient 1's "CT," dated 3/19/25, the CT indicated ". . .acute [sudden] subacute [a condition between acute and chronic] large infarct [an area of tissue that has died due to a lack of blood supply] . . ."

During a review of Patient 1's "EN," dated 3/20/25, the EN indicated, "Teleneuologist was consulted. . .contacted the transfer nurse for possible interventional neurologist consultation, I [MD 2] was connected with an interventional neurologist, she reviewed the images and reported that the patient at high risk of hemorrhagic [bleeding] conversion if embolectomy [a medical procedure that surgically removes a blockage in a blood vessel caused by a clot or other foreign material] was done. Furthermore, the long-term benefits and recovery for the patient is not guaranteed due to severity of the stroke and the acuity of radiologic changes. . ."

During a review of the hospital's policy and procedure (P&P) titled, "Rapid Response Team Adult & Pediatric," undated the P&P indicated, "Purpose: the goal of the rapid response team is to address the recognition of and response to an unexpected deterioration in a patient's condition. . .notwithstanding the RN's overall concern for changes in the patient's condition, he/she can activate the team based on the following criteria. . .Neurological Factors to Consider:. . .New motor/sensory function changes. . . notwithstanding the RN's overall concern for changes in the patient's condition, he/she can activate the team based on the following criteria a) staff or patient/family member concerned about the patient. . ."

During a review of the hospital's "P&P" titled, "Interdisciplinary Patient Assessment and Reassessment," undated the P&P indicated, "Reassessment: a) the patient will be reassessed: when there is a significant change in condition. . .b) Documentation of the reassessment will be located on the unit specific intervention flowsheet. c) Reassessments are completed by RN's ..."

During a review of the hospital's P&P titled, "Stroke Alert and Acute Care Stroke Management: Emergency Department and Inpatient Units," undated the P&P indicated, "This policy will also outline the procedure for implementing current evidence-based practice for the management and care of the patient presenting with signs and symptoms of acute stroke and to implement clinical practice guidelines to further reduce the morbidity and mortality associated with stroke these guidelines support the primary principles and detailed aspects of successful stroke systems of care. . . Policy: In recognition of the Stroke Chain of Survival, the SVMC stroke program strives to provide early recognition and appropriate treatment throughout the patients length of stay (LOS). To further the care continuum referral to appropriate post-acute care takes place. 1. Detection: Early recognition. . .D. Stroke Unit (Telemetry) RN or Medical Surgical RN performs and documents the NIHSS upon admission to the unit, with any change in condition, or as prescribed. Reports any change in condition to the attending provider. Performs neuro checks and vital signs as prescribed, and/or as needed. Is responsible for general nursing care of the stroke/TIA/stroke alert patient. . ."