HospitalInspections.org

Based on record reviews and interviews, the facility failed to provide General and Orthopedic services within its capability prior to the transfer of one (Sampled Patient, SP #1) of twenty-two sampled patients. SP #1 was transferred from Hospital #1 and the facility had the capability to provide the services needed by SP #1. Refer to the findings at A 2409.


Review of facility's documents on 4/2/15 showed the following corrective action plan: all ED physicians and ED nursing staff will be educated on Medical Screening and Duties of the On-call Physician policies, and sign-in sheet will be collected. Target completion date was 03/13/15. The involved On call physician would receive verbal education regarding the duties of the on call physician and that patients cannot be transferred outside the hospital's service capability. Target completion date was 03/09/15. Duties of on call physician has been placed on the agenda for the upcoming Medical Executive Committee, target date 03/13/15. Quality monitoring to include review of the transfer log of 100% of transfers, for four months.

Review of Physician sign-in sheet for Medical Screening and Duties of the On-call Physician education showed that two ED physicians did not receive education as of 04/02/15. On 04/02/15 at 2:30PM, the Quality Manager stated that the Duties of on call physicians was not placed on the agenda for the Medical Executive Committee for April 2015 and will be placed on the next agenda. On 04/02/15 at 3:45PM, the Director of Accreditation and Certification Services stated that all other corrective actions were completed. Review of facility's record showed that the other corrective actions were completed.

Based on reviews of medical records, policies and procedures, facility licenses, and interviews, the facility failed to provide General and Orthopedic services within its capability prior to the transfer of one (Sampled Patient, SP #1) of twenty-two sampled patients. SP #1 was transferred from Hospital #1 and the facility had the capability to provide the services needed by SP #1.

The findings included:


Review of the facility's policy, "Hospital to Hospital Transfer Policy," dated 10/04, documented in part, " Mount Sinai Medical Center is a full service hospital providing all acute care needs with the exception of pediatrics, burn patients, trauma patients and transplant services ...Definitions: A. Appropriate Transfer: ... (1) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health. "

Review of the facility's policy, "Medical Screening Policy," documents, the capabilities of the facility's staff mean the level of care that the hospital's personnel can provide within the training and scope of their professional licenses.

Review of the facility's license showed the facility provides general surgery, plastic surgery, and orthopedics services.

Review of SP#1 medical record showed that he arrived to the ED (emergency department) on 01/31/15 at 1:53 PM. According to the ED notes, the patient's chief complaint was abdominal pain with 2 days of emesis and diarrhea. The consultation notes on 01/31/2015 documented, SP #1 had an approximate 7 day history of right shoulder pain and erythema (redness) of the right shoulder in the subscapular region. He was previously seen at the ED where he underwent a brief evaluation and was discharged home.

The ED provider notes dated 01/31/15 at 2:59 PM document, the patient presented with right shoulder pain and swelling. Patient stated pain started two to three days ago localized to right shoulder, radiates distally to right hand and medially to right chest wall, described as swollen and red. Physician evaluation of the patient's right shoulder showed right shoulder was positive for swelling and edema that extends distally to the distal ends of the right hand involving the finger tips and radiates medially to the proximal shoulder and involves the right lateral chest wall and right lateral flank of the abdomen, positive for 2+ (plus) pitting edema with warmth and erythema on palpation.

The Computed Tomography (CT) scan of the right upper extremity results on 01/31/15 at 7:15 PM showed an ill-defined 8.4 x 3.8 cm gas and fluid collection at the right sub-scapularis muscle with extension to the right of the rotator cuff. There was also extension of fluid through the right axillary space, right upper shoulder and throughout the fascial planes of the right arm and lateral chest wall. There was extensive soft tissue swelling throughout the right shoulder joint as well as diffusely throughout the medial aspect of the right arm, right axilla, right thorax, and right flank extending to the level of the iliac. There was no fracture or suspicious osseous lesion. The CT of the chest, abdomen, and pelvis findings was sub-scapularis muscle concerning for myositis (muscle inflammation) with possible necrotizing fasciitis (fast acting flesh eating bacteria).

The plastic surgeon consultation report on 01/31/15 documented, the plan was to await an orthopedic surgery evaluation for possible irrigation, debridement, and washout of the shoulder and upper extremity fluid collection. General surgery will be involved as well, in case there is additional debridement needed to the chest wall. In addition, the patient has early multi-organ system failure (shut down of multiple body systems in face of uncontrolled sepsis) associated with necrotizing fasciitis.


The Orthopedic Consultation notes on 01/31/15 documented, the patient has severe sepsis (refers to a bacterial infection in the bloodstream or body tissues) with aggressive septicemia with possible necrotizing fasciitis involving retro-scapular, sub-scapula, right shoulder and upper extremity as well as frank lymphedema. The recommendation was that the patient required a highly specialized upper extremity surgeon evaluation for which recommendation was made to transfer to Hospital #2. The services required at the present time were not available in the institution.


On 1/31/15 at 8:26 PM, hospital #1 documented two physicians attempted to tap the right shoulder joint, but were unsuccessful, no fluid was aspirated. An Arthrocentesis was attempted. Only a scant amount of blood tinged fluid was obtained.

Review of the transfer form showed that the patient was transferred to (Hospital #2) on 01/31/15 at 10:30PM. The documented reason the transfer was required was medical services not available. The accepting physician was Dr. [named]. The consent for transfer was signed by the patient.


On 1/31/15 at 11:16 PM, the patient was transferred to hospital #2. The vital signs on 1/31/15 were documented as 122/68, 94% on room air, 98.5 Fahrenheit.

Review of the SP #1 medical record from hospital #2 showed the patient presented on 02/01/2015 with an illness since 1/23/2015 per mother with the patient experiencing shoulder pain. According to the operative reports, the patient underwent multiple procedures: an incision and drainage of the subscapular abscess and debridement of necrotic tissue on 02/05/2015; a washout and debridement of skin, subcutaneous tissue, muscle, and fascia from right side back subscapula space and chest on 02/06/2015; a wash out and debridement including the back, subscapular axilla and post pectoral region of the wound on 02/10/2015; a wound debridement, washout, and wound VAC placement on 02/13/2015 and 02/16/2015;and an incision and debridement of a right shoulder wound , removal of wound VAC management system on 02/19/2015; and an incision and drainage of right arm abscess and replacement of right chest wall back dressing on 02/28/2015.

On 02/18/15 at 1:35 PM, during the emergency access review, hospital #1's Chairman of the ED stated, SP#1 came into the ED with swelling. He stated that that there were concerns for necrotizing fasciitis and shoulder infection. He stated that the orthopedic surgeon said that they could not handle the case. He stated the ED physicians thought that SP#1 had trauma that got infected. He also stated that the physicians were not comfortable providing treatment to the patient for fear that they did not want to mess up the patient's arm which could lead to amputation. He stated that [named] Center at hospital #2 was contacted and the patient was accepted. He stated that necrotizing fasciitis is a fast acting flesh eating bacteria.

On 02/18/15 at 2:00 PM, during the emergency access review, the Orthopedic Surgeon stated that SP#1 had an aspiration done and was seen by the general surgeon. He stated that the patient had cellulitis (a common skin infection) in the scapula, shoulder, right thorax, rib cage, ribs, and right leg and needed aggressive intervention and treatment immediately. He stated that there was nothing that he could do as an orthopedic surgeon because the patient did not have any bones broken or out of place. He stated that he could not handle the patient and felt that the patient was best managed elsewhere. He stated that based on his level of expertise, he could not do the arm and chest. He stated that the patient' s condition was beyond his scope of orthopedic practice. He stated that he did not have any experience with necrotizing fasciitis.


On 02/18/15 at 2:57 PM, during the emergency access review, General Surgeon #2 stated that not all general surgeons are trained and have the expertise to handle necrotizing fasciitis. He stated that if the surgeon did not have the expertise, the patient needed to be transferred immediately.


The facility had capability (specialty services, Orthopedics and General surgery) and capacity to care for SP#1 on 1/31/2015. The facility inappropriately transferred SP #1 on 1/31/2015 based on the recommendation of the orthopedist without providing an evaluation of the patient prior to transfer.