HospitalInspections.org

Based on findings from medical record (MR) review, in 1 of 1 case reviewed, the emergency department (ED) care provided was not consistent with generally accepted standards of medical practice in the ED setting. In this case, even though an elderly patient on anticoagulation and cardiac medications (Patient A) presented to the ED after experiencing the second of 2 recent falls involving facial/head injuries, the ED physician did not document a complete neurological assessment, obtain a CT scan or provide appropriate follow up head injury instructions upon discharge.

Findings include:

-- Review of the MR for Patient A reveals this elderly patient presented to the ED via ambulance after falling a second time at his skilled nursing facility (SNF) residence. Patient A was noted to be alert and oriented X 3, with vital signs of blood pressure (BP) - 91/57, pulse (P) - 85, respirations (R) -14 and oxygen saturation (O2 sat) - 95%. His history included a fall 2 days ago during which he hit his head causing an ecchymosed area near his right eye. The second fall that prompted this ED visit resulted in new skin tears noted above the right eye and the right frontal area of the head; no active bleeding and no loss of consciousness reported. Patient A's medical history included (but was not limited to) congestive heart failure, borderline low BP, thyroid disease, cardiac disease, diabetes mellitus. His medications included aspirin & Plavix (anticoagulants), Coreg (antihypertensive), Lasix (diuretic), Glucotrol & Diabeta (antidiabetic agents) and Nitroglycerin (coronary vasodilator). The ED physician evaluated Patient A but did not order any laboratory or other diagnostic tests. Patient A was returned to the SNF with diagnoses of skin tears and bruises, with discharge instructions that addressed local wound treatment on the abrasions and continuation of all usual medications.

-- Review of Patient A's MR by a physician board certified in emergency medicine reveals the following:

The evaluation and diagnostic testing were not adequate for this elderly diabetic patient with cardiovascular disease on two (2) medications that increase risk of CNS (central nervous system) bleeding after head injury. It was clear that the patient had 2 falls and hit his head. At the least, a complete neurological exam was indicated, along with CT scan to rule out bleeding because of Plavix and aspirin use. With his blood pressure being borderline, a workup for volume loss (hematocrit) would be appropriate. As a diabetic, glucose check was indicated. It is the responsibility of the ED clinician to try to determine the cause of the fall, and to evaluate for neurological sequelae of potential brain injury in this high risk patient. This was not done. Skin/wound care was all that was provided.

Followup care was not appropriate as no head injury instructions sheet was given to the SNF staff to assess for brain injury or bleed.

The standard of care was not met.