HospitalInspections.org

Based on record review and interview the hospital failed to follow its policy to provide an adequate MSE (medical screening examination) for one of twenty patients sampled (patient # 1) seeking care from January 2011 to April 2011. The hospital failed to provide sampled patient #1 with an examination (MSE) sufficient to determine whether an emergency medical condition existed prior to discharge.

Findings include:

The hospital's policy, "Transfer of Individuals with Emergency Medical Conditions " reviewed on 4/4/11 at 2:15pm last revised on 2/2/07 specified that a "Medical Screening Examination" is an examination of the patient by a qualified medical professional who determines whether the patient is seeking treatment for an emergency medical condition. The hospital failed to follow this policy and did not provide patient #1 with an examination sufficient to determine whether patient #1 had an emergency medical condition prior to discharge on 3/15/11 at 9:33pm after 1 hour and 45 minutes in the ED (emergency department).

Sampled patient #1's ED record reviewed on 4/11/11 revealed patient #1, a 92 year old arrived at the hospital's ED by ambulance on 3/15/11 at 7:26pm from home after falling from a standing position in their kitchen. The ED nurse documented at 7:33pm patient #1's blood pressure was 153/75 and the patient complained of pain in their right knee.

ED physician M documented on 3/15/11 at 7:47pm that patient #1 injured their right knee, had a "moderate" degree of pain, a history of high blood pressure and hypothyroidism. The ED physician ordered x-rays of patient # 1 ' s right knee and documented the reason for the x-ray was "Fell 2 hours ago and unable to bear weight, and right knee pain."

ED nurse H documented at 8:55pm that patient #1 walked with assistance to the door and back. Patient #1's blood pressure after the short walk measured 201/89. Nurse H documented in the ED record and verified during interview on 4/4/11 that they notified the ED physician M who did not give any new orders to address or determine the cause for the patient ' s increased blood pressure. Patient #1 was discharged from the ED by wheelchair accompanied by a family member at 9:17pm (less than two hours after arrival by ambulance).

Patient #1's medical record reviewed on 4/4/11 did not contain evidence that prior to discharge ED physician M evaluated the cause of patient # 1's fall and inability to walk without assistance, the cause for patient #1's increased blood pressure (from 153/75 on arrival in the ED to 201/89), or if any health related complications contributed to their fall, pain and inability to walk without assistance.

The statutorily required physician peer review of patient #1's ED record and medical care performed on 5/20/11 identified the hospital failed to provide patient #1 with an appropriate and sufficient examination to determine whether an emergency medical condition existed prior to discharge on 3/15/11.

Family member A interviewed on 4/4/11 at 6:40pm stated after the fall, "Patient #1 could not walk and was in agony due to pain". Family member A indicated patient #1 had no problems walking and was independent prior to their fall. Family member A accompanied patient #1 to the emergency department on 3/15/11 and stated physician M did not examine patient # 1 or talk to the family until the time of discharge. Family member A stated they expressed concerns about discharge and patient #1's lack of ability to walk and care for themselves to ED physician M. Family member A stated ED physician M told them " there was no medical reason to keep patient #1 in the hospital ". ED physician M discharged patient #1 to home.

The medical record reviewed on 4/4/11 revealed patient # 1 returned to the ED on 3/18/11 at 10:07am, three days after discharge from the ED complaining of right knee pain and new onset of urinary incontinence. The ED mid-level practitioner examined patient #1 on 3/18/11 at 10:45am. The evaluation by the ED mid-level practitioner included blood samples for lab testing, urinalysis, a portable chest x-ray and x-rays of patient # 1's right hip, which revealed a subcapital fracture of the right femur described as a Garden 4 (hip fracture). Wheeless ' Textbook of Orthopedics defines a Garden 4 (hip fracture) as a complete fracture with total displacement requiring inpatient admission and surgical intervention.

See deficiency citation at A2406 for further details.

Based on record review and interview the hospital failed to provide an adequate MSE (medical screening examination) for one of twenty patients sampled (patient # 1) seeking care from January 2011 to April 2011 to determine whether an emergency medical condition existed prior to discharge.

Findings include:

- Sampled patient #1's ED record reviewed on 4/11/11 revealed patient # 1, a 92 year old arrived at the hospital's ED by ambulance on 3/15/11 at 7:26pm from home after falling from a standing position in their kitchen. The ED nurse documented at 7:33pm patient #1's blood pressure was 153/75 and the patient complained of pain in their right knee. ED physician M documented on 3/15/11 at 7:47pm that patient #1 injured their right knee, had a "moderate" degree of pain, a history of high blood pressure and hypothyroidism. The ED physician ordered x-rays of patient #1's right knee and documented the reason for the x-ray was "Fell 2 hours ago and unable to bear weight, and right knee pain."

ED nurse H documented at 8:55pm that patient #1 walked with assistance to the door and back. Patient #1's blood pressure after the short walk measured 201/89. Nurse H documented in the ED record and verified during interview on 4/4/11 that they notified ED physician M of their concerns with the patient's elevated blood pressure but received no new orders from the physician to address the patient ' s increased blood pressure or determine the cause for the increased blood pressure. ED staff documented patient #1 was given discharge instructions and the patient verbalized understanding of them. Patient # 1 was discharged from the ED by wheelchair accompanied by a family member at 9:17pm (less than two hours after arrival by ambulance).

Patient #1's medical record reviewed on 4/4/11 did not contain evidence that prior to discharge ED physician M provided an adequate MSE and evaluated the cause of patient #1's fall and inability to walk without assistance, the cause for patient #1's increased blood pressure (from 153/75 on arrival in the ED to 201/89), or if any health related complications contributed to their fall, pain and inability to walk without assistance.

- Family member A interviewed on 4/4/11 at 6:40pm stated after the fall, "My mother could not walk and was in agony due to pain". Family member A indicated patient #1 had no problems walking and was independent prior to their fall. Family member A accompanied patient #1 to the emergency department on 3/15/11 and stated physician M did not examine or talk to the family until ED physician M discharged patient #1. Family member A stated they expressed concerns about discharge and patient #1's lack of ability to walk and care for themselves to ED physician M. Family member A stated ED physician M told them " there was no medical reason to keep patient #1 in the hospital ". ED physician M discharged patient #1 to home.


- The medical record reviewed on 4/4/11 revealed patient #1 returned to the ED on 3/18/11 at 10:07am, three days after discharge from the ED complaining of right knee pain and new onset of urinary incontinence. The ED mid-level practitioner examined patient #1 on 3/18/11 at 10:45am. The evaluation by the ED mid-level practitioner included blood samples for lab testing, urinalysis, a portable chest x-ray and x-rays of patient # 1's right hip, which revealed a subcapital fracture of the right femur described as a Garden 4 (hip fracture). Wheeless ' Textbook of Orthopedics defines a Garden 4 (hip fracture) as a complete fracture with total displacement requiring inpatient admission and surgical intervention.

- The statutorily required physician peer review of patient #1's ED record and medical care performed on 5/20/11 identified the hospital failed to provide patient # 1 with an appropriate and sufficient examination (MSE) to determine whether an emergency medical condition existed prior to discharge on 3/15/11.