HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that in 1 of 20 (Pt. #1) clinical records reviewed, the Hospital failed to ensure that all patients presenting to the Hospital's Emergency Department receive an ongoing Medical Screening Exam; see A 2406.

A. Based on clinical record review and staff interview, it was determined that, for 1 of 20, (Pt. #1) clinical records reviewed for patients who presented to the emergency department for evaluation, the Hospital failed to ensure an ongoing medical screening exam was provided by the physician to determine if an emergency medical condition exists.

Findings include:

1. On 2/07/11 at approximately 11:00 AM, the clinical record for Pt. #1 was reviewed. Pt. #1, a 21 year old male, presented to Norwegian American Hospital emergency department(ED) in the company of a family member on 1/29/11 at 11:33 AM, with complaints of left- sided facial pain after sustaining an injury while using exercise equipment. Pt. #1 was triaged on 1/29/11 at 11:33 AM. Vital signs were: B/P 128/73, pulse 98, resp 18, pulse ox 99% and temp. 98.7. The pain level was listed as a 9 on a pain scale of 0-10. The triage category was listed as 4 (semi-urgent). While in the ED, Pt #2 received IV fluids, a CT scan and pain medication.

The initial medical screening exam (by MD #1), dated 1/29/11 at 11:45 AM included, Pt. here with c/o pain to left side of the face after he was injured by a metal exercise spring, which hit him the face. Pt. was dazed and fell to ground after the trauma, no LOC, no n/v. Pt. denies any other trauma and had no tooth loss or bleeding from nose. Pt. c/o pain at the jaw and trouble with opening the mouth ...left face with gross swelling at jaw, no open areas in the mouth at dental line, there is some trimus, unable to feel mandible bone secondary to swelling but very tender, zygoma left non tender, nose stable ...maxilla non tender, small abrasion to right lateral forehead without tenderness or defects...alert, appears in severe pain."

MD#1 ordered a CT scan which showed a "minimally displaced fracture of the mandible on the left with associated soft tissue swelling both medially and laterally from the mandible, may be secondary to soft tissue hematoma. There is considerable shift of the midline structures to the right. Also noted is prominence of tonsils. Preliminary report was sent to MD #1 after the exam was performed and additionally discussed in detail with MD #2."

At 1:10 PM, as documented in the clinical record, MD#1 called another hospital for consultation since Norwegian American Hospital does not have a maxillofacial specialist. The consultation with oral surgeon, stated the patient did not qualify as a trauma transfer, but Pt. # 1 could follow-up on Monday at the office. At 1:30 PM, MD #1 endorsed the case to MD #2. The progress note from MD#1 stated, Oral Maxillofacial from consulting hospital will call to advise a plan. "MD#2 aware and will help facilitate plan."
Documentation by MD #2 has no time of entry and no physical assessment. Untimed progress note by MD #2 states, Consulting Hospital called back stating pt. does not qualify as a trauma transfer, but the oral surgeon will call back when they want to see the pt. Oral surgeon returned call and will have pt. f/u on Monday morning at his office. The only assessment progress note by MD # 2 states, "The pt. was treated in the ER and feels improved and able to be discharged. The Pt. has been cautioned about signs of worsening condition and advised to return to the ER or see their doctor if this should occur."

MD #2 failed to provide an ongoing medical screening exam from 1330 when MD #2 accepted Pt. #1 to disposition of pt. #1 at 1445. It could not be determined through record review if Pt. #1's condition was stabilized prior to discharge because there was no documentation of an ongoing screening examination by MD #2.

2. On 2/7/11 at approximately 1:50 PM, MD #1 was interviewed by telephone. MD #1 stated that Pt. #1 was stable at the time of transfer to MD#2 and appeared to be comfortable. Follow up care would be provided by a specialist.

3. The clinical record from receiving Hospital was reviewed on 2/8/11 at approximately 1:45 PM. Pt. #1 arrived to the receiving Hospital emergency department on 1/30/11 (approximately 24 hrs after being discharged from Norwegian American Hospital) at 12:21 PM for evaluation of a jaw fracture. The ED physician documented "mandible ecchymosis,swelling, neck edema. Vital signs were: temp 99.0, pulse 110, resp 20 and B/P 124/78." The physician re-evaluation timed at 5:45 PM included information that the CT scan performed at the receiving hospital showed evidence of narrowed airway. At 7:00 PM, Pt. #1 went to the OR with anesthesia and an ENT physician for nasal intubation. Post intubation, Pt. #1 was admitted to Surgical Intensive Care. On 2/4/11, Pt. #1 had an open reduction and internal fixation of the left mandibular fracture and was discharge from the Hospital on 2/6/11.

4. The above findings were confirmed with the Administrative Team on 2/7/11 at 4:00 PM.

5. On 2/11/11 at approximately 10 AM, MD#3 from receiving Hospital was interviewed by telephone. MD#3 stated that Pt.#1 arrived at receiving Hospital on 1/30/11 at approximately 12 Noon with complaint of a swollen neck. A CT Scan was done 1/30/11 which showed a potential compromise of PT.#1 airway. MD#3 also stated that he asked Pt.#1 if he "felt any better or any worse", since his visit to Norwegian Medical Center. Pt.#1 told MD#3 that he was having trouble breathing. MD#3 immediately notified a Surgeon and an Anesthesiologist. Pt.#1 was taken to the Operating Room and had a successful control intubation and subsequently admitted to the Surgical Intensive Care Unit.