Based on hospital policy review, medical record review, and physician interview the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: The hospital's Dedicated Emergency Department (DED) qualified medical professional failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 32 sampled patients (Pt #29) who presented to the hospital's DED for evaluation and treatment. ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A2406

Based on policy and procedure review, medical record reviews, and physician interview, the hospital's Dedicated Emergency Department (DED) failed to provide a thorough Medical Screening Examination (MSE) within its capability, including ancillary testing, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 32 sampled patients who presented to the hospital's DED for evaluation and treatment (Pt # 29) potentially resulting in treatment delay. The findings include: Review of Hospital Policy titled "EMTALA COMPLIANCE, INCLUDING PATIENT TRANSFERS (EMERGENCY MEDICAL TREATMENT AND LABOR ACT), dated 05/15, revealed "...SUMMARY STATEMENT Emergency services and care, including an appropriate Medical Screening Examination, will be provided to individuals who 'come to the emergency department' and request examination or treatment of a medical condition, as defined in this policy. A Medical Screening Examination will be done to determine if an Emergency Medical Condition exists. If the individual has an Emergency Medical Condition, the hospital will either stabilize the medical condition within it available staff, facilities, and resources, or, if stabilization at the hospital is not possible, appropriately transfer the individual to a qualified receiving facility....I. Medical Screening Examination ....B. Appropriate MSE . The purpose of the MSE is to determine whether the individual has an EMC. 1. The MSE should be appropriate based on the signs and symptoms of the individual, and in keeping with the professional standard of care. 2. The MSE must be done within the capacity and capability of the hospital, including using all ancillary services routinely available to the Emergency Department....II. Personnel A. Qualified Medical Personnel.... 2. When medically appropriate, a MSE will include consultation with the on-call physician. ..." DED medical record review for Patient #29 revealed the [AGE] year old patient arrived to the DED on 12/26/2017 at 1232. Review of ED Triage Note, at 1240, revealed a stated complaint of " ...left sided weakness during the night." Review revealed Patient #29 was assigned an acuity of "2 - Emergent" and vital signs were T 97.4, P 61, R 20, BP 146/106, SpO2 98% on room air, and no pain present. ED Physician Documentation notes, time seen 1235, revealed " ...Patient woke up this morning with left leg weakness and had some difficulty ambulating. He stated that he felt fine when he went to bed last night ....no fevers, no vomiting, no trauma. No headache. Symptoms are moderate. They have improved at this point ....Physical Exam ....General: Well-appearing alert in no acute distress. HEENT (head, eyes, ears, nose, throat): PERRLA (pupils equal, round, reactive to light and accommodation), atraumatic, normocephalic, oropharynx is clear moist mucous membranes. Neck: Supple no lymphadenopathy Cardiac: S1-S2 regular no murmurs rubs or gallops ....Neuro: GCS (Glasgow Coma Scale) is 15, alert, moving all extremities equally 5 out of 5 strength bilateral upper and lower extremities. No pronator drift. Extraocular movements are full. Visual fields are full. Procedure EKG: Sinus rhythm, bigeminy, no signs of acute ischemia Medical Decision Making Patient with left-sided weakness that has improved significantly. Suspect TIA (Transient Ischemic Attack). Stroke bleed also possible. We will CT head check labs and reevaluate. Patient's no code stroke due to delayed presentation and rapid improvement symptoms." Review revealed an EKG, Chest X-Ray, laboratory studies, and a Head CT without contrast were completed. Review of the CT revealed " ... IMPRESSION: 1. No acute intracranial findings are noted. ..." Review of a Clinical Assessment note revealed at 1415 " ...patient ambulated in room with some difficulty requiring him to hold on to something or someone. patient family states he is ambulating per his norm." Further review of ED Physician Documentation notes revealed " ...Reexamination/Reevaluation CT head is negative for acute finding. Laboratories are unremarkable. Patient is had (as written) full resolution of symptoms and is ambulatory. He will be discharged for follow-up with primary care for further workup Diagnosis: TIA Condition: Stable Disposition: Home." Review revealed a follow-up appointment was set with a PCP on 12/29/2017 at 1421 (3 days later). Review of Discharge Instructions, Checkout Date/Time: 12/26/2017 at 1444 revealed the reason for visit was stroke like symptoms and discharge diagnosis was brain TIA. DED record review revealed "Emergency Medical Condition Identified: D/C - Identified EMC, STABLE at time of disposition decision." Review of Vital Signs at 1430 revealed BP 138/82, P 80 (monitored), R 26, SpO2 96%. Record review revealed Patient #29 was discharged home with family member at 1444. DED record review did not reveal an echocardiogram (echo), MRI, or carotid ultrasounds were done. Review of provider documentation did not reveal notation of a neurological exam of all twelve cranial nerves, sensation in extremities, or testing of reflexes in the extremities. Review did not show a NIH (National Institutes of Health) Stroke Scale Score and did not reveal evidence of a neurology consult. Telephone interview, on 02/22/2018 at 1830, with MD #2 revealed he was the treating physician for Patient #29. Interview revealed the patient presented with left sided weakness, was not a code stroke patient, and the symptoms improved. MD #2 stated there were no concerns with lab or CT results and on exam there were no focal neurologic symptoms. In interview MD #2 indicated the symptoms fit more with TIA. MD #2 stated TIA's could be followed up as an outpatient, that multiple studies had shown outpatient care to be effective. Interview revealed Patient #29 would need a carotid study, MRI, and echo, which could be done on an outpatient basis in a week or two. The 30 day risk of a full stroke was small, the physician stated, if the patient returned to baseline. Patient #29 was already on aspirin, he stated, and was [AGE] years old. MD #2 stated he preferred not to err on admitting a very elderly patient because of the risks associated with sundowning, falls, and infections in the hospital. Interview revealed MD #2 always discussed for TIA patients to return to the ED immediately if symptoms returned. This Patient, he stated, had good support and follow-up, had stable vital signs and labs, and had returned to baseline. MD #2 stated he had no concerns with discharging the patient.