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Based on review of the medical record, policies and procedures, staff interviews and other pertinent documentation, it was determined the hospital failed to provide care in a safe setting for patient #1.

Based on review of the medical record, policies and procedures staff interviews and other pertinent documentation, it was determined that the hospital failed to follow current standards of practice and policies and procedures in the care of patient #1. The hospital failed to follow it's own protocol and therefore provide adequate treatment for rabies exposure as evidenced by:

Patient #1 is a 6 year old female brought to Baltimore Washington Medical Center (BWMC) on 2/28/10 after being bitten by a raccoon. The animal was not caught. Per the medical record review the patient was admitted at 7:30pm. Patient had temperature 37 degrees, pulse 140 beats per minute, respiration 20 breaths per minute, oxygen saturation of 98%. Per the hospital's Emergent Rabies Prophylaxis Protocol, which corresponds to the CDC and Anne Arundel County Health Department guidelines the following actions should have been taken by the hospital staff:
1. Assessment of the wound site and surrounding tissue.
2. Immediately cleanse the wounds with soap and water.
3. Irrigate the wounds with Providone-Iodine Solution.
4. Obtain the physician decision regarding vaccination administration.
5. If bite occurred in Anne Arundel County call AA CO. Police Department/Animal Control.
6. Administer HRIG 20IU/kg of body weight. If anatomically feasible infiltrate full dose around the wound. Any remaining volume, change the needle and administer intramuscularly (IM) at an anatomically distant site from the vaccine administration site. For adults the vaccination should always be injected into the Deltoid (arm). For children, the anterior-lateral aspect of the thigh is also acceptable.

The Human Rabies Immune Globulin provides immediate antibodies while the body can respond to the vaccine by actively providing antibodies on its own. Additional doses should be administered on days 3,7, and 14 after the first vaccination.

Per the medical record, patient #1 had injuries about the head, face, upper back left shoulder and left superior pinna. Four lacerations were noted on the left ear, three requiring sutures to close. Under the procedures section which had no documented time it was noted that the wounds were irrigated with saline and explored. It was documented at 8:30pm that the patient was offered Acetaminophen/Hydrocodone 15ml, which the parents refused. There is a copy of a vaccination card. Written at the top of this card is Day 0 2/28 left deltoid. The discharge instructions include scheduled follow-up dates for vaccine series, wound care, medications and instruction to follow-up with her pediatrician. The patient was discharged at 11:30pm.

On admission to the ED the physical exam was performed which included an assessment of the wound site and the surrounding tissue. The Anne Arundel Fire Department Transport Form noted the patient had lacerations on the left ear, chest, back and left hand. The triage nurse documented at 7:08pm that the patient had bite marks present to her left hand, back and left ear. The nurse in the main ED documented at 7:19pm the patient had a laceration to left ear and bilateral back. The physician assistant documented via a diagram that the patient had four lacerations on the left ear and an abrasion on the left shoulder. At this point there is a inconsistency in the documentation regarding the number of wounds and sites. The wound to the chest and left hand were not mentioned after the triage nurse examination and the abrasion on the back changed from bilateral (both sides) to the left shoulder. The mother stated that the pediatrician found a wound on the patient's buttocks and left ear. If the patient was disrobed and a thorough skin assessment completed why the inconsistency in the documented wounds.

The protocol also states the wounds are to be cleansed immediately with soap and water and then irrigated with povidone-iodine solution. Review of the medical record revealed the only documentation that cleansing with soap and water occurred at 9:55pm to the bilateral back abrasions. The physician assistant irrigated the wound with saline instead of the povidone-iodine solution.

There is no documentation that the patient was weighed on admission. The weight of 20kg was noted on the Potential Rabies Exposure Health Department Reporting Form and the Anne Arundel County Fire Department Transport Form. The mother stated when she was asked about how much patient #1 weighed, she stated around 45 pounds. The nurse did not weigh patient #1, instead she calculated the vaccine dosage using an inaccurate weight. Three days later while reviewing the incident with the Anne Arundel County Health Department the mother realized the vaccine dosage is calculated based on the patient weight. The patient was weighed and her actual weight was 53 pounds requiring the patient to receive additional vaccine. The additional dosage was supplied by the Health Department within the 3 day window for vaccination.