Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure compliance with 42 CFR 489.24(a) failure to complete an appropriate Medical Screening Examination (MSE), 42 CFR 489.24(d)(3)failure to provide Stabilizing Treatment, and 42 CFR 489.24(d)(4) Delay in Treatment for one (1) patient (Patient #1), in the selected sample of twenty (20) patients. Reference tags: A-2406, A-2407, and A-2408

Based on interview, record review, review of the facility's policy, and review of the facility By-Laws, it was determined the facility failed to conduct a complete and appropriate Medical Screening Examination (MSE) for one (1) patient (Patient #1), in the selected sample of twenty (20) patients. The findings include: Review of the facility By-Laws revealed all patients who presented to the emergency room (ER) will receive an appropriate MSE, receive stabilizing treatment, and will be either discharged , admitted , or transferred. Review of the facility's "Stroke Protocol" revealed for patients who presented with stroke-like symptoms with symptom onset within the previous three (3) hours, a "Code Fast" will be initiated to determine if the patient is a Tissue Plasminogen Activator (tPA) candidate. If the patient is not a candidate, the ER will do lab work, a Computed Tomography (CT) of the head without contrast, cardiac monitoring; also, a National Institute of Health (NIH) stroke scale assessment will be completed by the ER Physician, and neurological checks will be completed every hour. Review of Patient #1's medical record revealed he/she arrived at the ER, on 04/30/18 at 7:44 AM, with a complaint of weakness in the left arm and left leg, onset after falling. The patient stated he/she landed on his/her left side and hit his/her arm and leg on a brick fireplace. He/she denied loss of consciousness, had an abrasion to the left elbow, upper left arm, and left knee. Further record review revealed the family reported the patient had frequent falls. The patient's airway was patent with good air movement, and he/she was breathing without difficulty. The patient was pink, warm, dry, and heart rate was within normal limits. According to the record, the patient had weakness or paralysis of his/her extremity and complained of pain in his/her left arm and left leg. Further review of the medical record, dated 04/30/18 at 7:47 AM, revealed his/her blood pressure was 160/72, pulse 79, respirations 20, temperature 97.8 degrees Fahrenheit (F), pulse oximetry (ox) 98%, and pain noted as zero (0) out of ten (10). Vital signs were taken hourly. At 10:50 AM, his/her blood pressure was 138/66, pulse 70, respirations 16, and pulse ox 99%. The Emergency Department Doctor (EDD) ordered lab tests, Carotid Doppler, CT of the head without contrast, and intravenous fluids (IV) fluids. Review of the Carotid Doppler impression revealed there were small to moderate amounts of plaque in the carotid vasculature, with no narrowing of 50 percent (%) or greater identified. Review of the CT of the brain without contrast impression revealed there was a mild mucosal thickening in the sinus, mild cerebral atrophy, and no hemorrhage, mass or acute ischemic change was identified. Additional review of the medical record revealed the impression was a Transient Cerebral Ischemic Attack (TIA), unspecified - with left sided weaknesses, stroke-like symptoms, weakness left sided, and acute kidney failure, unspecified. No deficits were noted and condition was stable. Discharge instructions included Stroke Prevention and follow-up with the Primary Care Physician (PCP) to get a Magnified Resonance Image (MRI) of the brain. Review of the Nurse's note written by Registered Nurse (RN) #1 (in Triage), on 04/30/18 at 7:52 AM, revealed the patient could not get up from the chair without difficulty or ambulate without assistance. Further record review revealed, from the time the patient arrived to Hospital #1 until the time he/she left the hospital, his/her symptoms had improved. Review of the Emergency Department Director (EDD)'s MSE notes, dated 04/30/18 at 7:54 AM, revealed a walk-in patient (Patient #1) presented with symptoms of weakness to the left side and a possible stroke, reporting the patient's problem as left-sided facial drooping, weakness in the upper left extremity, the lower left extremity, and the left side of the face. Review of the onset revealed the symptoms/episode occurred the day before, at home, while he/she was walking. Review of the duration revealed the episode was continuous, and symptoms were aggravated by nothing. Review of associated signs and symptoms, and pertinent positives were weakness. Review of severity of symptoms revealed, at their worst, the symptoms were moderate, on 04/30/18, and in the ER, the symptoms were unchanged. Review of the patient's baseline revealed, neurologically, he/she was alert and fully oriented, with no motor deficits. Review of ambulation revealed he/she walked without assistance, and his/her speech was normal. Further record review revealed the patient had not experienced similar symptoms in the past, and the patient had not seen a Physician recently. Review of systems, dated 04/30/18 at 7:56 AM, revealed all other systems were negative, except positive for laceration(s) on the left arm. Review of the neurological system revealed positive for weakness of the left hand, left foot, left arm, and left leg. At 7:58 AM, noted by the EDD, possible contributing factors included the patient was a known diabetic with hypertension. Further review, dated 04/30/18 at 8:05 AM, revealed an NIH Stroke Scale of two (2). The patient's eye response revealed spontaneous (4), while verbal response revealed he/she was oriented (5), and motor response revealed he/she obeyed commands (6), with a total of fifteen (15). Interview with the EDD, on 05/08/18 with no time recorded, revealed he saw Patient #1 in the ER, who presented with stroke-like symptoms after a fall. He reported Patient #1 came to the ER twenty-four (24) hours after the onset of symptoms. He ordered a CT scan and Carotid Doppler to see if an MRI was emergently warranted. He stated the CT scan did not show an acute stroke and the carotid doppler did not show a significant plaque blockage, the patient had minimal deficits, and his/her vital signs were normal. Additionally, he reported Patient #1's symptoms were over twenty-four (24) hours old, so no MRI was ordered and it was possible the patient's left sided weakness was due to his/her reported fall. The patient was discharged with a diagnosis of stroke-like symptoms, TIA unspecified with left sided weakness, kidney failure unspecified and instructions to follow-up with his/her Primary Care Physician (PCP) for an MRI. Interview with Registered Nurse (RN) #2, on 05/08/18 at approximately 1:03 PM, revealed Patient #1 was talkative and friendly. She reported the patient appeared to have no deficit. RN #2 stated she never saw the patient out of the bed. Interview with RN #4, on 05/08/18 at approximately 3:58 PM, revealed she gave the discharge paperwork to the family, which included the Physician's instructions for the patient to have a follow-up MRI. She reported Patient #1 was discharged in a wheelchair and she did not actually see the patient ambulate. Interview with the Emergency Medical Director (EMD), on 05/08/18 at approximately 9:59 AM, revealed an MRI was not done as an emergent procedure, and was not the treatment of choice for an acute stroke. He stated it was not part of stroke protocol in the beginning and an MRI was a follow-up. He reported the CT scan was the treatment of choice to determine the type of stroke. He stated admission for observation, or not, was the clinical judgement of the Physician. He stated what was done was clinically appropriate, that the patient was stable, and his/her vital signs were fine. Patient #1 did get an MRI that day. He/she was stable enough and treatment could be done outpatient. He stated, "I believe everything I reviewed was done appropriately". Interview with the Chief Nursing Officer (CNO), on 05/07/18 at approximately 3:12 PM, revealed Patient #1 had a CT Scan which showed no acute changes, and an Ultra Sound (US), which showed nothing; therefore, the patient was discharged . Further interview with the CNO, on 05/08/18 at approximately 11:10 AM, revealed an MRI was not part of the immediate stroke protocol. Review of Patient #1's medical record from Hospital #2, revealed on 05/01/18, Patient #1 went via ambulance to Hospital #2's ER. Patient #1 reported he/she was in a normal state, on 04/29/18 at approximately 3:00 PM. He/she was walking across the floor and suddenly his/her left leg went out from under him/her. He/she recalled being somewhat dizzy for twenty-four (24) hours prior, but definitively had no deficits before that time. He/she did not seek medical care right away. The Physician noted Patient #1 had left lower facial drooping, left arm weakness, and left leg weakness. The next morning he/she attempted to get out of bed and fell several times to the left. He/she went to the ER, on 04/30/18, where a CT of the head was done along with routine lab work and a carotid US, which was unremarkable. The Physician stated the patient's spouse and daughter-in-law, who was a nurse, were present at the bedside when the EDD suggested he/she had a stroke or a TIA. The family was told he/she required an MRI, but had to be done through the PCP. They immediately went to the PCP and had the MRI done, but did not know the results at that time. The MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. It was noted the patient fell four (4) times subsequent to being discharged on [DATE]. Patient #1 was admitted to Hospital #2 after having an MRI the previous day which showed a Cerebrovascular Accident (CVA). He/she had weakness in his/her left upper and lower extremity with some abrasions on his/her left upper extremity. Further review revealed the CT of the brain and cervical spine were unremarkable, as well as labs being unremarkable, except for Chronic Kidney Disorder (CKD). Review of Patient #1's medical record from the PCP revealed he/she went to the PCP on 04/30/18 and had an MRI, and the PCP received the results of the MRI. Results/Impression revealed there was a recent area of ischemia on the right side. There were findings of mild atrophy and a small vessel ischemic change. There was increased signal in the sinuses, suggesting possible sinusitis versus mucous retention or polyps. Review of the MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. Interview with the PCP, on 05/08/18 at approximately 3:15 PM, revealed Patient #1 was told to see him after being discharged from Hospital #1's ER and the patient did so on the same day (04/30/18). He reported the patient had a facial droop on the left side and looked like he/she had a complete stroke. He revealed he ordered an MRI for Patient #1, which showed he/she did have a stroke, and his office was in the process of contacting the patient. He began setting the patient up for therapy; however, Patient #1 had already gone to another hospital (Hospital #2).

Based on interview, record review, review of the facility's policy, and review of the facility's By-Laws, it was determined the facility failed to provide stabilizing treatment for one (1) patient (Patient #1), in the selected sample of twenty (20) patients. The findings include: Review of the facility By-Laws revealed all patients who presented to the emergency room (ER) will receive an appropriate MSE, receive stabilizing treatment, and will be either discharged , admitted , or transferred. Review of the facility's "Stroke Protocol" revealed for patients who presented with stroke-like symptoms with symptom onset within the previous three (3) hours, a "Code Fast" will be initiated to determine if the patient is a Tissue Plasminogen Activator (tPA) candidate. If the patient is not a candidate, the ER will do lab work, a Computed Tomography (CT) of the head without contrast, cardiac monitoring; also, a National Institute of Health (NIH) stroke scale assessment will be completed by the ER Physician, and neurological checks will be completed every hour. Review of Patient #1's medical record revealed he/she arrived at the ER, on 04/30/18 at 7:44 AM, with a complaint of weakness in the left arm and left leg, onset after falling. The patient stated he/she landed on his/her left side and hit his/her arm and leg on a brick fireplace. He/she denied loss of consciousness, had an abrasion to the left elbow, upper left arm, and left knee. Further record review revealed the family reported the patient had frequent falls. The patient's airway was patent with good air movement, and he/she was breathing without difficulty. The patient was pink, warm, dry, and heart rate was within normal limits. According to the record, the patient had weakness or paralysis of his/her extremity and complained of pain in his/her left arm and left leg. Further review of the medical record, dated 04/30/18 at 7:47 AM, revealed his/her blood pressure was 160/72, pulse 79, respirations 20, temperature 97.8 degrees Fahrenheit (F), pulse oximetry (ox) 98%, and pain noted as zero (0) out of ten (10). Vital signs were taken hourly. At 10:50 AM, his/her blood pressure was 138/66, pulse 70, respirations 16, and pulse ox 99%. The Emergency Department Doctor (EDD) ordered lab tests, Carotid Doppler, CT of the head without contrast, and intravenous fluids (IV) fluids. Review of the Carotid Doppler impression revealed there were small to moderate amounts of plaque in the carotid vasculature, with no narrowing of 50 percent (%) or greater identified. Review of the CT of the brain without contrast impression revealed there was a mild mucosal thickening in the sinus, mild cerebral atrophy, and no hemorrhage, mass or acute ischemic change was identified. Additional review of the medical record revealed the impression was a Transient Cerebral Ischemic Attack (TIA), unspecified - with left sided weaknesses, stroke-like symptoms, weakness left sided, and acute kidney failure, unspecified. No deficits were noted and condition was stable. Discharge instructions included Stroke Prevention and follow-up with the Primary Care Physician (PCP) to get a Magnified Resonance Image (MRI) of the brain. Review of the Nurse's note written by Registered Nurse (RN) #1 (in Triage), on 04/30/18 at 7:52 AM, revealed the patient could not get up from the chair without difficulty or ambulate without assistance. Further record review revealed, from the time the patient arrived to Hospital #1 until the time he/she left the hospital, his/her symptoms had improved. Review of the Emergency Department Director (EDD)'s MSE notes, dated 04/30/18 at 7:54 AM, revealed a walk-in patient (Patient #1) presented with symptoms of weakness to the left side and a possible stroke, reporting the patient's problem as left-sided facial drooping, weakness in the upper left extremity, the lower left extremity, and the left side of the face. Review of the onset revealed the symptoms/episode occurred the day before, at home, while he/she was walking. Review of the duration revealed the episode was continuous, and symptoms were aggravated by nothing. Review of associated signs and symptoms, and pertinent positives were weakness. Review of severity of symptoms revealed, at their worst, the symptoms were moderate, on 04/30/18, and in the ER, the symptoms were unchanged. Review of the patient's baseline revealed, neurologically, he/she was alert and fully oriented, with no motor deficits. Review of ambulation revealed he/she walked without assistance, and his/her speech was normal. Further record review revealed the patient had not experienced similar symptoms in the past, and the patient had not seen a Physician recently. Review of systems, dated 04/30/18 at 7:56 AM, revealed all other systems were negative, except positive for laceration(s) on the left arm. Review of the neurological system revealed positive for weakness of the left hand, left foot, left arm, and left leg. At 7:58 AM, noted by the EDD, possible contributing factors included the patient was a known diabetic with hypertension. Further review, dated 04/30/18 at 8:05 AM, revealed an NIH Stroke Scale of two (2). The patient's eye response revealed spontaneous (4), while verbal response revealed he/she was oriented (5), and motor response revealed he/she obeyed commands (6), with a total of fifteen (15). Interview with the EDD, on 05/08/18 with no time recorded, revealed he saw Patient #1 in the ER, who presented with stroke-like symptoms after a fall. He reported Patient #1 came to the ER twenty-four (24) hours after the onset of symptoms. He ordered a CT scan and Carotid Doppler to see if an MRI was emergently warranted. He stated the CT scan did not show an acute stroke and the carotid doppler did not show a significant plaque blockage, the patient had minimal deficits, and his/her vital signs were normal. Additionally, he reported Patient #1's symptoms were over twenty-four (24) hours old, so no MRI was ordered and it was possible the patient's left sided weakness was due to his/her reported fall. The patient was discharged with a diagnosis of stroke-like symptoms, TIA unspecified with left sided weakness, kidney failure unspecified and instructions to follow-up with his/her Primary Care Physician (PCP) for an MRI. Interview with RN #4, on 05/08/18 at approximately 3:58 PM, revealed she gave the discharge paperwork to the family, which included the Physician's instructions for the patient to have a follow-up MRI. She reported Patient #1 was discharged in a wheelchair and she did not actually see the patient ambulate. Interview with the Emergency Medical Director (EMD), on 05/08/18 at approximately 9:59 AM, revealed an MRI was not done as an emergent procedure, and was not the treatment of choice for an acute stroke. He stated it was not part of stroke protocol in the beginning and an MRI was a follow-up. He reported the CT scan was the treatment of choice to determine the type of stroke. He stated admission for observation, or not, was the clinical judgement of the Physician. He stated what was done was clinically appropriate, that the patient was stable, and his/her vital signs were fine. Patient #1 did get an MRI that day. He/she was stable enough and treatment could be done outpatient. He stated, "I believe everything I reviewed was done appropriately". Interview with the Chief Nursing Officer (CNO), on 05/07/18 at approximately 3:12 PM, revealed Patient #1 had a CT Scan which showed no acute changes, and an Ultra Sound (US), which showed nothing; therefore, the patient was discharged . Further interview with the CNO, on 05/08/18 at approximately 11:10 AM, revealed an MRI was not part of the immediate stroke protocol. Review of Patient #1's medical record from Hospital #2, revealed on 05/01/18, Patient #1 went via ambulance to Hospital #2's ER. Patient #1 reported he/she was in a normal state, on 04/29/18 at approximately 3:00 PM. He/she was walking across the floor and suddenly his/her left leg went out from under him/her. He/she recalled being somewhat dizzy for twenty-four (24) hours prior, but definitively had no deficits before that time. He/she did not seek medical care right away. The Physician noted Patient #1 had left lower facial drooping, left arm weakness, and left leg weakness. The next morning he/she attempted to get out of bed and fell several times to the left. He/she went to the ER, on 04/30/18, where a CT of the head was done along with routine lab work and a carotid US, which was unremarkable. The Physician stated the patient's spouse and daughter-in-law, who was a nurse, were present at the bedside when the EDD suggested he/she had a stroke or a TIA. The family was told he/she required an MRI, but had to be done through the PCP. They immediately went to the PCP and had the MRI done, but did not know the results at that time. The MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. It was noted the patient fell four (4) times subsequent to being discharged on [DATE]. Patient #1 was admitted to Hospital #2 after having an MRI the previous day which showed a Cerebrovascular Accident (CVA). He/she had weakness in his/her left upper and lower extremity with some abrasions on his/her left upper extremity. Further review revealed the CT of the brain and cervical spine were unremarkable, as well as labs being unremarkable, except for Chronic Kidney Disorder (CKD). Review of Patient #1's medical record from the PCP revealed he/she went to the PCP on 04/30/18 and had an MRI, and the PCP received the results of the MRI. Results/Impression revealed there was a recent area of ischemia on the right side. There were findings of mild atrophy and a small vessel ischemic change. There was increased signal in the sinuses, suggesting possible sinusitis versus mucous retention or polyps. Review of the MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. Interview with the PCP, on 05/08/18 at approximately 3:15 PM, revealed Patient #1 was told to see him after being discharged from Hospital #1's ER and the patient did so on the same day (04/30/18). He reported the patient had a facial droop on the left side and looked like he/she had a complete stroke. He revealed he ordered an MRI for Patient #1, which showed he/she did have a stroke, and his office was in the process of contacting the patient. He began setting the patient up for therapy; however, Patient #1 had already gone to another hospital (Hospital #2).

Based on interview, record review, and review of the facility By-Laws, it was determined the facility failed to conduct a complete and appropriated Medical Screening Examination (MSE) and stabilizing treatment, which caused a delay in treatment, for one (1) patient (Patient #1), in the selected sample of twenty (20) patients. The findings include: Review of the facility By-Laws revealed all patients who presented to the emergency room (ER) will receive an appropriate MSE, receive stabilizing treatment, and will be either discharged , admitted , or transferred. Review of the facility's "Stroke Protocol" revealed for patients who presented with stroke-like symptoms with symptom onset within the previous three (3) hours, a "Code Fast" will be initiated to determine if the patient is a Tissue Plasminogen Activator (tPA) candidate. If the patient is not a candidate, the ER will do lab work, a Computed Tomography (CT) of the head without contrast, cardiac monitoring; also, a National Institute of Health (NIH) stroke scale assessment will be completed by the ER Physician, and neurological checks will be completed every hour. Review of Patient #1's medical record revealed he/she arrived at the ER, on 04/30/18 at 7:44 AM, with a complaint of weakness in the left arm and left leg, onset after falling. At 7:47 AM, acuity was emergent. The patient stated he/she landed on his/her left side and hit his/her arm and leg on a brick fireplace. He/she denied loss of consciousness, had an abrasion to the left elbow, upper left arm, and left knee. Further record review revealed the family reported the patient had frequent falls. The patient's airway was patent with good air movement, and he/she was breathing without difficulty. The patient was pink, warm, dry, and heart rate was within normal limits. According to the record, the patient had weakness or paralysis of his/her extremity and complained of pain in his/her left arm and left leg. Method of arrival was walk in. Further review of the medical record, dated 04/30/18 at 7:47 AM, revealed his/her blood pressure was 160/72, pulse 79, respirations 20, temperature 97.8 degrees Fahrenheit (F), pulse oximetry (ox) 98%, and pain noted as zero (0) out of ten (10). Vital signs were taken hourly. At 10:50 AM, his/her blood pressure was 138/66, pulse 70, respirations 16, and pulse ox 99%. The Emergency Department Doctor (EDD) ordered lab tests, Carotid Doppler, CT of the head without contrast, and intravenous fluids (IV) fluids. Review of the Carotid Doppler impression revealed there were small to moderate amounts of plaque in the carotid vasculature, with no narrowing of 50 percent (%) or greater identified. Review of the CT of the brain without contrast impression revealed there was a mild mucosal thickening in the sinus, mild cerebral atrophy, and no hemorrhage, mass or acute ischemic change was identified. At 7:51 AM, the Triage Assessment revealed the onset of the patient's symptoms were more than six (6) hours ago. Additional review of the medical record revealed the impression was a Transient Cerebral Ischemic Attack (TIA), unspecified - with left sided weaknesses, stroke-like symptoms, weakness left sided, and acute kidney failure, unspecified. No deficits were noted and condition was stable. Discharge instructions included Stroke Prevention and follow-up with the Primary Care Physician (PCP) to get a Magnified Resonance Image (MRI) of the brain. Review of the Nurse's note written by Registered Nurse (RN) #1 (in Triage), on 04/30/18 at 7:52 AM, revealed the patient could not get up from the chair without difficulty or ambulate without assistance. Further record review revealed, from the time the patient arrived to Hospital #1 until the time he/she left the hospital, his/her symptoms had improved. Review of the Emergency Department Director (EDD)'s MSE notes, dated 04/30/18 at 7:54 AM, revealed a walk-in patient (Patient #1) presented with symptoms of weakness to the left side and a possible stroke, reporting the patient's problem as left-sided facial drooping, weakness in the upper left extremity, the lower left extremity, and the left side of the face. Review of the onset revealed the symptoms/episode occurred the day before, at home, while he/she was walking. Review of the duration revealed the episode was continuous, and symptoms were aggravated by nothing. Review of associated signs and symptoms, and pertinent positives were weakness. Review of severity of symptoms revealed, at their worst, the symptoms were moderate, on 04/30/18, and in the ER, the symptoms were unchanged. Review of the patient's baseline revealed, neurologically, he/she was alert and fully oriented, with no motor deficits. Review of ambulation revealed he/she walked without assistance, and his/her speech was normal. Further record review revealed the patient had not experienced similar symptoms in the past, and the patient had not seen a Physician recently. Review of systems, dated 04/30/18 at 7:56 AM, revealed all other systems were negative, except positive for laceration(s) on the left arm. Review of the neurological system revealed positive for weakness of the left hand, left foot, left arm, and left leg. At 7:58 AM, noted by the EDD, possible contributing factors included the patient was a known diabetic with hypertension. Further review, dated 04/30/18 at 8:05 AM, revealed an National Institute of Health (NIH) Stroke Scale of two (2). The patient's eye response revealed spontaneous (4), while verbal response revealed he/she was oriented (5), and motor response revealed he/she obeyed commands (6), with a total of fifteen (15). Interview with the EDD, on 05/08/18 with no time recorded, revealed he saw Patient #1 in the ER, who presented with stroke-like symptoms after a fall. He reported Patient #1 came to the ER twenty-four (24) hours after the onset of symptoms. He ordered a CT scan and Carotid Doppler to see if an MRI was emergently warranted. He stated the CT scan did not show an acute stroke and the carotid doppler did not show a significant plaque blockage, the patient had minimal deficits, and his/her vital signs were normal. Additionally, he reported Patient #1's symptoms were over twenty-four (24) hours old, so no MRI was ordered and it was possible the patient's left sided weakness was due to his/her reported fall. The patient was discharged with a diagnosis of stroke-like symptoms, TIA unspecified with left sided weakness, kidney failure unspecified and instructions to follow-up with his/her Primary Care Physician (PCP) for an MRI. Interview with Registered Nurse (RN) #2, on 05/08/18 at approximately 1:03 PM, revealed Patient #1 was talkative and friendly. She reported the patient appeared to have no deficit. RN #2 stated she never saw the patient out of the bed. Interview with RN #4, on 05/08/18 at approximately 3:58 PM, revealed she gave the discharge paperwork to the family, which included the Physician's instructions for the patient to have a follow-up MRI. She reported Patient #1 was discharged in a wheelchair and she did not actually see the patient ambulate. Interview with the Emergency Medical Director (EMD), on 05/08/18 at approximately 9:59 AM, revealed an MRI was not done as an emergent procedure, and was not the treatment of choice for an acute stroke. He stated it was not part of stroke protocol in the beginning and an MRI was a follow-up. He reported the CT scan was the treatment of choice to determine the type of stroke. He stated admission for observation, or not, was the clinical judgement of the Physician. He stated what was done was clinically appropriate, that the patient was stable, and his/her vital signs were fine. Patient #1 did get an MRI that day. He/she was stable enough and treatment could be done outpatient. He stated, "I believe everything I reviewed was done appropriately". Interview with the Chief Nursing Officer (CNO), on 05/07/18 at approximately 3:12 PM, revealed Patient #1 had a CT Scan which showed no acute changes, and an Ultra Sound (US), which showed nothing; therefore, the patient was discharged . Further interview with the CNO, on 05/08/18 at approximately 11:10 AM, revealed an MRI was not part of the immediate stroke protocol. Review of Patient #1's medical record from Hospital #2, revealed on 05/01/18, Patient #1 went via ambulance to Hospital #2's ER. Patient #1 reported he/she was in a normal state, on 04/29/18 at approximately 3:00 PM. He/she was walking across the floor and suddenly his/her left leg went out from under him/her. He/she recalled being somewhat dizzy for twenty-four (24) hours prior, but definitively had no deficits before that time. He/she did not seek medical care right away. The Physician noted Patient #1 had left lower facial drooping, left arm weakness, and left leg weakness. The next morning he/she attempted to get out of bed and fell several times to the left. He/she went to the ER, on 04/30/18, where a CT of the head was done along with routine lab work and a carotid US, which was unremarkable. The Physician stated the patient's spouse and daughter-in-law, who was a nurse, were present at the bedside when the EDD suggested he/she had a stroke or a TIA. The family was told he/she required an MRI, but had to be done through the PCP. They immediately went to the PCP and had the MRI done, but did not know the results at that time. The MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. It was noted the patient fell four (4) times subsequent to being discharged on [DATE]. Patient #1 was admitted to Hospital #2 after having an MRI the previous day which showed a Cerebrovascular Accident (CVA). He/she had weakness in his/her left upper and lower extremity with some abrasions on his/her left upper extremity. Further review revealed the CT of the brain and cervical spine were unremarkable, as well as labs being unremarkable, except for Chronic Kidney Disorder (CKD). Review of Patient #1's medical record from the PCP revealed he/she went to the PCP on 04/30/18 and had an MRI, and the PCP received the results of the MRI. Results/Impression revealed there was a recent area of ischemia on the right side. There were findings of mild atrophy and a small vessel ischemic change. There was increased signal in the sinuses, suggesting possible sinusitis versus mucous retention or polyps. Review of the MRI was positive for an acute area of ischemia in the right centrum semiovale ovale. Interview with the PCP, on 05/08/18 at approximately 3:15 PM, revealed Patient #1 was told to see him after being discharged from Hospital #1's ER and the patient did so on the same day (04/30/18). He reported the patient had a facial droop on the left side and looked like he/she had a complete stroke. He revealed he ordered an MRI for Patient #1, which showed he/she did have a stroke, and his office was in the process of contacting the patient. He began setting the patient up for therapy; however, Patient #1 had already gone to another hospital (Hospital #2).