Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings included: 1. The hospital's DED failed to provide an appropriate Medical Screening Examination (MSE), to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 37 sampled DED patients who presented to the hospital for evaluation and treatment of signs and symptomns of suspected stroke (Patient #4). ~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination Condition, Tag A2406.

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, physician interview and staff interview, the hospital's DED failed to provide an appropriate Medical Screening Examination (MSE), to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 37 sampled DED patients who presented to the hospital for evaluation and treatment for signs and symptoms of [DIAGNOSES REDACTED] Findings included: Review on 08/29/2017 of the current hospital policy titled "EMTALA Policy", revised 12/2016, revealed, "...____(Hospital Name) is committed to complying with the Emergency Medical Treatment and Active Labor Act, 42 U.S.C 1395 and the implementing regulations (EMTALA). EMTALA requires that a hospital with an emergency department to provide to any individual who is not a patient of the hospital and who "comes to the emergency department" an appropriate medical screening evaluation within the capability of the hospital's emergency department to determine whether an EMC exists, regardless of the individual's ability to pay...Emergency Department Patient Medical Screening..Scope...An individual is considered to have "come to the emergency department" if the individual is not an Existing patient and: The individual has presented at a DED and requests examination or treatment for a medical condition, or has such a request made on his or her behalf." A medical record review on 08/29/2017 for patient #4 revealed the [AGE] year-old female presented to the hospital's DED via private vehicle on 04/03/2017 at 1443 with a complaint documented as "Suspected Stroke...Per family, pt (patient) has had slurred speech and gait issues for one week." The documentation revealed the patient was triaged by DED RN #1 at 1443 who documented the patient was an "ESI (Emergency Severity Index) 3." At 1455 the review revealed the patient received an EKG (electrical recording of the heart) for suspected "TIA/Stoke" while in the triage area. Vital signs taken at 1449 in triage revealed the patient's pulse as "79" beats per minute and blood pressure as "133/77." With no documentation of the patient being brought into the DED treatment area, the DED Physician #1 documented at 1504 that the EKG interpretation for the patient as "Atrial Fibrillation/Flutter, Right Bundle Branch Block, Left Ventricular Hypertrophy, Anterior Infarct, Significant Rhythm Changes, Abnormal EKG." Documentation at 1645 revealed a fingerstick blood sugar for the patient was elevated at "170." The next documentation in the medical record was for vital signs being repeated at 1753 (Total of 3 hours and 4 minutes since triage vitals) by Nursing Assistant #1 with readings as "106" pulse (increased from 79) and blood pressure of "143/92" (increased). No documentation was found in the medical record that the nursing assistant made the nursing staff aware of the increase in the patient's heart rate. Review of the hospital's current policy "Triage Process", revised 12/2016, revealed , "...Reassessment...Patients in the Emergency Department waiting room will have vital signs reassessed based on the triage acuity level: Category III- every 2 hours." Review of the patient's medical record revealed the patient's vital signs were reassessed at 3 hours and 4 minutes (Total of 1 hour and 4 minutes greater than 2 hour requirement) after being triaged as ESI #3 (Category III). Further review of patient #4's medical record for 04/03/2017 revealed the patient was not given a room assignment and remained in the waiting room. The documentation revealed documentation from the DED RN #2 at 1929 that patient #4 was called in the waiting room with no answer. Documentation at 1934 by DED RN #3 revealed an overhead page was done in the lobby of DED twice with no patient answer. The review also revealed that DED RN #2 again documented calls for the patient twice at 1939 and three more times at 1945. The documentation revealed the patient left without treatment after the documentation revealed the patient was potentially in the DED waiting room with a complaint of suspected stroke and EKG reading as "Atrial Fibrillation/Flutter, Right Bundle Branch Block, Left Ventricular Hypertrophy, Anterior Infarct, Significant Rhythm Changes, Abnormal EKG" for a total of 5 hours and 2 minutes. Interview on 08/30/2017 at 1305 with the DED Physician #1 revealed that he did read patient #4's EKG but did not see the patient on 04/03/2017. The physician revealed the patient had [DIAGNOSES REDACTED]rate and stroke symptoms reported for a week. The interview revealed that if cardiac problems are a potential, then we do an EKG and it was up to the triage nurse for the order of patients to come back. The physician stated that he felt the patient had [DIAGNOSES REDACTED]but not needing to have to be brought back in the DED and it was up to the triage nurse. Interview on 08/30/2017 at 1630 with the DED RN #1 revealed that he was working as triage nurse on 04/03/2017 when patient #4 presented to the DED. The interview revealed his documentation revealed the patient presented with her family who were concerned the patient had a suspected stroke. The interview revealed the patient was triaged as ESI 3 and had an EKG done in triage area with DED Physician #1 reading the EKG. The interview also revealed that a fingerstick glucose was done to rule out low sugar levels for the patient as well as the patient's vital signs were normal during triage. The patient's neurological assessment was reported as done and no symptoms were noted by the nurse. The interview revealed "If we have full department, ESI 2s and 3s may go back to lobby." The interview also revealed that the nurse thought vital signs for ESI 3 was reassessed every 4 hours but he was not sure and would have to look at the policy. The interview also revealed that if patients in the lobby have abnormal vital signs, the nursing assistants should let the nursing staff know. The interview also revealed for patient #4, since the patient's pulse went from 79 to 106 on reassessment, the nursing assistant should have made the nursing staff aware of the changes. The interview indicated no documentation was found to indicate that the nursing staff was aware of the patient's change in heart rate. The interview further revealed that he got off of duty at 1900 on 04/03/2017 while the patient was still in the DED. Interview on 08/31/2017 at 0840 with DED RN #3 revealed that she was the triage nurse on 04/03/2017 starting her shift at 1900. The interview revealed that she did not remember specifics about patient #4 but after reviewing the patient's medical record that she was the assigned triage nurse for 1900 during the patient's DED visit. The interview also revealed that she did not see any documentation nor did she remember the nursing assistant #1 reporting patient #4's vital signs to her for 1853. The interview also revealed that if the patient's "106" pulse change was reported to her that she would have addressed the change. The DED RN revealed that the nursing assistant was from the hospital's "Central Staffing" and that she may not have been as familiar as other nursing assistants in knowing to report vital sign changes to the nursing staff. The interview revealed the process in the DED is for the nursing assistants to report abnormal vital sign changes to the nursing staff for patients waiting in the lobby to be taken to the back. An interview was attempted with nursing assistant #1 but the nursing assistant was no longer employed or available for interview. In summary, patient #4 was brought to the hospital's DED on 04/03/2017 by private vehicle with her family who reported the patient had a suspected stroke with symptoms of [DIAGNOSES REDACTED]#1 revealed the patient had an abnormal EKG that included significant changes and [DIAGNOSES REDACTED]as the patient was placed in the lobby. The patient had triage vital signs taken with an reassessment of vital signs taken 3 hours and 4 minutes later with changes in the patient's pulse that increased from 79 to 106. No documentation was found that the nursing assistant reported the change of the patient's vital signs to either triage nurse while the patient was in the lobby. The nursing staff attempted to call the patient after the patient was documented as in the DED for a total of 5 hours and 2 minutes before being documented as left without treatment.

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: The hospital failed to ensure a physician who was on call for ophthalmology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 36 sampled patients that presented with an emergency medical condition (Patient #22). ~ Cross refer to §489.20(r)(2) and §489.24(j)(1-2) On Call Physicians - Tag A2404.

Based on policy and procedure review, medical record review, on call schedule review and staff and physician interviews, the hospital failed to ensure a physician who was on call for ophthalmology services was available to provide services upon the request of the dedicated emergency department (DED) physician for 1 of 36 sampled patients that presented with an emergency medical condition (Patient #22). The findings include: Review of the "Medical Staff Policy on Consultant Physician Response to the Emergency Department" (not dated) revealed "... Policy for emergency situations: In response to a request from an attending physician seeing a patient in the ED (emergency department), the consultant physician on-call will come to the ED without delay." Review of the hospital's "EMTALA Policy" revised 02/2014 and reviewed 02/2016 revealed "... On-Call Physician Responsibility under EMTALA ... Procedure 1. The Chief of Service of each department shall provide a list of on-call physicians from the respective department and their assigned coverage times. The list shall be submitted to the chairman of the emergency department. This will describe 24-hour per day coverage, each day of the month, and include contact information for all physicians on call. All specialties privileged in this hospital shall have a specific call list. All active members of the medical staff are required to serve pro-rata share of on-call duty for their specialty and to respond to call during scheduled on-call periods, and to physically report to the Emergency Department or other requesting department in a Timely Manner to assume care of any patient requiring their attendance. ...3. ... Where the on-call physician disagrees with the emergency physician on the need to respond, the on-call physician shall respond, and after rendering care, may address the disagreement to the director of the Emergency Department or to the chairperson of the on-call physician's department for evaluation and remedial actions, if indicated. ... Definitions ... Timely Manner: A timely response by an on-call physician who is not on Hospital Property is deemed to be 45 minutes to 60 minutes under normal conditions from initial call to appearance in the Emergency Department. For non-urgent consultations, the emergency physician and the consultant should agree on the response for the Emergency Department consultation, up to 4 hours. ..." Closed medical record review of Patient #22 revealed a [AGE] year-old male that presented to the hospital's dedicated emergency department (DED) on 06/04/2015 at 2101 via private and was triaged at 2107. Review of the nursing triage note revealed the patient presented with a chief complaint of blindness with partial vision loss in the left eye, progressing over the last two day. Review revealed the patient was sent to the DED by VA (Veterans Administration) who were concerned for detached retina. Review revealed the patient complained of blindness in the right side of his left eye for one and one half days. Review revealed the patient had a history of diabetes and was on oral medication for this. Review of nursing notes revealed a visual assessment was recorded at 2321 with right eye acuity of 20/30, left eye acuity of 20/200 and both eyes visual acuity of 20/25. Review of the DED physician's medical screening examination revealed the patient was evaluated at 2321 with a presenting history of "vision loss in the left eye since this morning. Has one week h/o (history of) floaters and occasional poor vision. Patient denies pain in eye. Has worsening vision over last two days, acutely worsened this afternoon. States loss of vision felt like a curtain coming from below. ... This is a new problem. The current episode started 12 to 24 hours ago. The problem occurs constantly. The problem has not changed since onset. ..." Review of the physician's notes recorded "Medical Decision Making/Plans: ...presents with acute painless vision loss, suspicious for retinal detachment or vitreous hemorrhage. Discussed with (on-call) ophthalmology. Will see in AM. Place in obs (observation) until AM. ..." Review revealed the resident physician (MD #1) discussed the patient with the attending physician (MD #2). Review of DED physician notes recorded by MD #2 (attending physician) on 06/05/2015 at 0016 revealed the patient's wife had called an ophthalmologist in the location of residence and was told to come to Hospital A's DED to see an eye doctor tonight. Further review of the DED physician's note recorded "Patient and wife are upset that they will not be seen tonight. The resident called (ophthalmologist on-call - MD #3) and I spoke with her a second time. States the (sic) there is nothing to do tonight and they were given the wrong info. She did not want to come in and felt the patient could be seen in the office in the morning. I d/w (discussed with) the patient their options: 1 - call the optho (ophthalmologist) a 3rd time and have them come in. 2 - stay in the ED (I'll make an arrangement to keep them) and potentially have them seen in the morning before d/c (discharge). 3 - stay in the ED as above and go to their appointment in the a.m. 4 - go home and come back in the morning, not optimal given distance and time of day. Patient is willing to stay here and be d/c first thing in the morning to be seen by optho. ..." Review of MD #2 notes recorded at 0745 revealed "Patient was able to use connections to get in touch with (another ophthalmologist) office. He is awaiting call back. He wants to be d/c (discharged ) so he can get over there to the office." Review revealed a physician order to discharge the patient at 0753. Review revealed discharge instructions were provided to go right over to the on-call ophthalmologist office to be seen and to see another ophthalmologist if possible. Review revealed the patient departed the DED on 06/05/2015 at 0822. Review of the record revealed MD #2 documented a return telephone call to the patient on 06/06/2015 at 1315 that revealed the physician "Called patient today and he had surgery on "both" eyes yesterday. He waited at (on-call ophthalmologist office) for 1.5 hours in the morning then went to see another specialist in Raleigh. He says that he is doing much better but that post op he will have slow restoration of vision. He was told that it would have been much worse if he waited longer." Review of the on call schedule for 06/04/2015 revealed MD #3 was on-call for ophthalmology. MD #1 (DED resident physician) and MD #2 (DED attending physician) were interviewed on 05/15/2016 at 0845. MD #1 stated Patient #22 came in with loss of vision and a questionable detached retina. MD #1 stated he called the ophthalmologist on-call (MD #3) and asked for the best plan. MD #1 stated MD #3 would see the patient the next morning. The physician stated he didn't remember the conversation but that "typically we would like them to come in (to see the patient)." MD #2 (attending physician) stated he placed a second telephone call to MD #3 (on-call ophthalmologist). MD #2 stated "They (patient and wife) wanted to see the ophthalmologist and I wanted them to see the ophthalmologist sooner than in the morning. She did not want to come in and felt the patient could be seen in the morning. She said there was nothing to do tonight." Interview revealed MD #2 provided the patient options of calling the on-call ophthalmologist back a third time to come in or having the patient stay in the ED overnight and the patient opted to stay overnight and see the on-call ophthalmologist in the morning. MD #2 stated "I didn't think it would change (patient's condition) drastically, but I also wouldn't have made a second call if I wasn't concerned. They understood that the ophthalmologist wasn't a retinal specialist and they knew about the previous calls. The mentioned a (another ophthalmologist). He is a retinal specialist. There was discussion surrounding him. I think they expected to see an ophthalmologist when they walked in. I called back to try to get her to come in. I wouldn't call someone at that time of night unless I needed them to come in." Further interview with MD #2 revealed "I made a follow up phone call to the patient because I was concerned and wanted to make sure he got care. He told me he got surgery on both eyes. He had gone to the (on-call ophthalmologist) office as requested. I don't remember how he ended up in Raleigh. They (patient and wife) knew she (on-call ophthalmologist) was not a retinal specialist. Yes, I wanted her to come in and I wouldn't have made a second call if I was not needing her to come in. I could have called the Chief Medical Officer and would have on the third call. The patient decided to stay overnight and go to the office in the morning." Telephone interview on 05/04/2016 at 1620 with MD #3 revealed she was the ophthalmologist on call beginning at 0800 on 06/04/2015 through 0800 on 06/05/2015. MD #3 stated she remembered Patient #22. The physician stated the patient presented with a 4 day history of floaters and flashes of light and she was called sometime after 2200. Interview revealed she talked with the resident and recommended a plan for the patient to see a retinal specialist in her office the following morning. MD #3 stated she was not a retinal specialist and thought the patient had a possible retinal detachment and would need to see a retinal specialist. MD #3 stated the patient would need care within 24 hours if there was a detachment and that she felt the patient's condition wouldn't change. The physician stated "If I had come in, I wouldn't have changed the plan. I would still recommend he go to the office at 0800 the next day. We have specialized equipment available at the office that is not available at the hospital." MD #3 was asked about the second phone call from MD #2 (DED attending physician). MD #3 stated "I thought he wanted to verify the plan to come in the next day. He did not express any concerns." Interview with MD #3 revealed Patient #22 did not see the retinal specialist the next day because the retinal specialist was not available. Interview revealed the patient was seen by another ophthalmologist in the office and diagnosed with a retinal detachment and referred to a retinal specialist in Raleigh.