HospitalInspections.org

Based on review of the Emergency Department (ED) Central Log, medical record review, review of the on-call physician schedules, and interviews, the facility failed to provide an appropriate medical screening examination, failed to provide stabilizing treatment, and failed to prevent a delay in treatment for one patient (Patient #16) who presented to the ED on two separate occasions with complaints of pain and swelling to the right ankle, for one of 30 ED patients reviewed.

The findings include:

Patient #16 presented to the ED at Hospital A on 12/25/2021 with pain and swelling to the right ankle, abrasions to the right foot, and refusal to bear weight following an injury of the right lower extremity. Vital signs and a medical screening examination (MSE) were completed for the patient. X-rays were obtained of the right ankle, right foot, and right tibia/fibula bones which were read with no abnormal findings from the provider in the ED and the radiologist. The patient was discharged home with instructions to wash abrasions with soap and water daily, apply ice, elevate extremity to reduce pain and swelling, children's ibuprofen 9 ml (milliliters) by mouth every 6 hours for 3 days to reduce pain and inflammation, and to follow up with her primary care provider on 12/28/2021 for recheck if she was not improving or if she was still refusing to bear weight.

Patient #16 returned to Hospital A's ED on 12/27/2021 with continued pain to the right lower extremity. Vital signs and an MSE were completed for the patient. X-rays were obtained of the right foot and right tibia/fibula which were read with no abnormal findings from the provider in the ED and the radiologist. The patient was discharged home with instructions to follow up with the pediatrician in the next couple of days for re-evaluation, set up an orthopedist appointment, and may take ibuprofen 8.5 ml by mouth every 6 hours.

Patient #16 presented to the ED at Hospital B on 1/1/2022 with pain in the right foot and continuing to refuse to bear weight on the right extremity. Vital signs and an MSE were completed for the patient. X-rays were obtained of the right femur, right tibia/fibula, and right foot. A splint was applied to the right lower extremity. The patient was discharged home with instructions to see the pediatric orthopedist within the week and stay non-weight bearing with splint until the appointment.

Patient #16 was seen outpatient by the pediatric orthopedist on 1/6/2022 where a closed nondisplaced transverse fracture of shaft of right tibia was diagnosed from the original right tibia x-ray obtained on 12/25/2022 at Hospital A.

Refer to A-2406 and A-2407.

Based on review of the Emergency Department (ED) Central Log, medical record review, review of the physician on-call schedules, and interview, the facility failed to provide an appropriate medical screening examination for one patient (Patient #16) who presented to the ED on two separate occasions with complaints of pain and swelling to the right ankle, for one of 30 ED patients reviewed.

The findings include:

Review of the facility's ED central log revealed Patient #16 presented to the ED for treatment on 12/25/2021 and 12/27/2021.

Medical record review revealed Patient #16 presented to the ED on 12/25/2021 with complaints of pain and swelling in her right foot and abrasions to her right foot.

Medical record review of the Emergency Room Medical Note dated 12/25/2021 at 11:22 PM revealed, "...the patient is a 3 ½ year old female who presents to the ER [Emergency Room] today with her father for complaints of pain and swelling to her right ankle and abrasions to her right foot...The dog's leash became wrapped around her right foot. The patient attempted to pull away, and she injured her right ankle. She sustained abrasions to the dorsum of her right foot. She has been refusing to bear weight since the injury occurred at 6:00 PM...Cries tears and screams throughout entire physical exam. Refuses to put her right foot on the floor...extremities: mild abrasions noted to the dorsum of the right foot. Mild swelling noted to lateral aspect of the right ankle. Patient seems to have tenderness to palpation to the dorsum of the right foot and diffusely to the right ankle...[Patient #16] was seen in the ER for pain and swelling to her right ankle and abrasions and pain to her right foot and refusal to bear weight following an injury...x-rays of her right ankle, right foot, and right lower leg were normal on preliminary reading...these will also be reviewed by the radiologist...we will call if the radiologist reads something differently...she sustained a right ankle sprain and right foot abrasions...please see her primary care provider on Tuesday December 28th for recheck if she is not improving or if she is still refusing to bear weight...please return to ER sooner for worsening redness, worsening swelling, worsening pain, fever 100.4 or higher with refusing to bear weight, or any other new worsening symptoms..."

Medical record review of diagnostic testing dated 12/25/2021 at 11:20 PM revealed, "...XR [x-ray] foot right...findings: There is no evidence of fracture or other bony abnormality...impression: No acute finding of the right foot...XR ankle right...findings: There is no evidence of fracture of other bony abnormality. The growth plates are within normal limits. No soft tissue abnormality...Impression: normal...XR Tib [tibia bone] fib [fibula bone]...findings: there is no evidence of fracture or other bony abnormality. Impression: No acute finding of the right tibia/fibula..."

Patient #16 was discharged from the ED on 12/25/2021 at 11:48 PM with diagnoses of right ankle sprain and right foot abrasions.

Review of the December 2021 physician on-call schedule for the ED revealed there was an orthopedic physician available for consultation on 12/25/2021.

Medical record review revealed the orthopedic physician on call for 12/25/2021 was not consulted to see Patient #16.

Medical record review revealed Patient #16 presented back at the ED on 12/27/2021 with complaints of continued pain in right foot.

Medical record review of Emergency Room Medical Note dated 12/28/2021 (after midnight) at 5:44 AM revealed, "...Chief complaint: R [right] foot inj [injury] 12/25, neg [negative] xray. Still c [with] pain...presents with concerns for right lower extremity pain. The patient was seen here on December 25th for the same complaint...The patient had normal x-rays and was diagnosed with a sprain. She was sent home with supportive care. But mom says the patient has continued to complain of pain. Mom brought the patient back for further evaluation. Mom denies any increased swelling, joint redness, or fever. She says the patient acts like she hurts whenever she goes to walk. She says the patient's pain appears to be in her foot...the patient's right lower extremity appears normal to visual inspection with no soft tissue swelling, joint erythema [redness or inflammation], or deformity. Anywhere I touch on her foot, she cries and pulls away...She can wiggle her toes...There are no cuts or lesions on her foot and there are no lesions between her toes...the patients x-rays look normal. We will send her to her pediatrician with ortho [orthopedic] referral...Diagnosis: (1) Right foot pain...referrals: [Orthopedic]...[Patient #16's] exam was reassuring and her x-rays look normal. Her films will be officially read by the pediatric radiologist later in the morning and we will notify you if they have any additional findings. As discussed, we recommend follow up with the orthopedist if she does not improve. This appointment can be arranged on your own or through her pediatricians office...recheck with her pediatrician in the next couple of days for re-evaluation and to set up the ortho appointment. Return to the ER for any worsening pain, red or swollen joints, if you think she is worse in general, or if you are simply worried about her condition..."

Medical record review of diagnostic testing dated 12/27/2021 at 5:07 AM revealed, "...XR tib fib...findings: there is no evidence of fracture or other bony abnormality. Impression: Normal right tibia and fibula...XR foot right...findings: There is no evidence of fracture or other bony abnormality. Impression: Normal right foot..."

Patient #16 was discharged home on 12/28/2021 at 5:51 PM with diagnosis of right lower extremity pain.

Review of the December 2021 physician on-call schedule for the ED revealed there was an orthopedic physician available for consultation on 12/27/2021.

Medical record review revealed the orthopedic physician on call for 12/27/2021 was not consulted to see Patient #16.

Medical record review of an orthopedic follow up for Patient #16 on 1/6/2022 at 2:40 PM revealed, "...[Patient #16] comes in today with mother with complaints of right leg injury. Apparently back on Christmas Day, she tripped over the dog leash, twisting her leg. She was seen at [Hospital A] where x-rays were done of the tibia and foot. She was sent home. Mother states she continued in pain, went back to [Hospital A] on the 28th, where x-rays were done again. Again, they did not see a fracture, so she was sent home...On exam today, she is a healthy-appearing...toddler. She has no obvious tenderness to palpation along the tibia. She has good range of motion of the knee and ankle without pain. She has a small bruise on the dorsum of the ankle from the wrap that she was in...AP [anterior posterior] and lateral [x-ray] done of the right tibia at [Hospital A] on [12/25/2021], read by me today [orthopedist] show a nondisplaced oblique fracture of the mid to distal tibial shaft...I have told the mother this is a classic toddler's fracture. They are very hard to see on plain x-ray. Treatment will be to put her into a weightbearing short leg cast. I will see her back in 2 weeks..."

Interview with the Director Quality and Patient Safety on 1/25/2022 at 11:25 AM confirmed Patient #16 was seen in the ED on 12/25/2021 and 12/27/2021, complaining of leg pain after a fall. Patient #16 was taken to Hospital B because of continued leg pain and then sent to a pediatric orthopedist for treatment after misdiagnosis at Hospital A on 12/25/2021 and 12/28/2021. The pediatric orthopedist was able to observe the fracture on 12/25/2021 x-rays, but not on the 12/28/2021 x-rays. Interview confirmed it was difficult to see those type of fractures without the specialty of pediatric orthopedics and toddler fractures could be difficult to diagnose.

Interview the Emergency Department physician on 1/25/2022 at 3:53 PM revealed, "...I did not personally examine the patient so they [mid-level provider] don't talk to me about the patient unless they have issues...They are more than welcome to ask me to see a patient..."

Interview with the Medical Director of the Emergency Department on 1/26/2022 at 10:46 AM revealed, "...so I looked at the medical records with both visits and the images. The difference with orthopedics with a 3-year-old is the open growth plates. So, fractures with that age are sometimes radiographically normal and those aren't able to be diagnosed until clinical follow up. So, a lot are diagnosed because they don't get better over time or begin bearing weight. Occult fracture is what it's called and that is why [the Physician's Assistant] referred them to orthopedics after the return visit to the ER..."

Interview with Physician's Assistant #1 on 1/26/2022 at 5:28 PM revealed "...from my charting the physical exam wasn't anything impressive. I usually repeat the x-ray if they are having the same complaint because sometimes the calcium will seep from the bone days after a fracture, and you can later see one on imaging that wasn't visualized days prior...I looked over the film myself once I got the chart and didn't see one [fracture], but the radiologist reading it is usually the definitive...Because we had two x-rays here at the ER that didn't show anything, but she was still having pain, outpatient pediatric ortho was the most appropriate for her...If she had had a fever we would have thought about a possible infection, or obvious fracture that needed surgery, and would have possibly consulted with ortho [orthopedic specialist] on call. These types of injuries either get better on their own or we refer to outpatient orthopedist and that's where she was at that point. If I just had a kid that just had an injury, two negative x-rays, I'm not thinking this is an occult fracture. Our thinking is let's give it a few more days and refer them to ortho...It's going to be the best decision to let the specialist make that call. I will go consult the physician if a parent gives me any indication, they are not happy, just to reassure that parent or double check us if we have any concerns at all. But no, [ED physician] was not consulted that evening and did not see the patient..."

The facility failed to complete an appropriate medical screening examination on 12/25/2021 and 12/27/2021 by not utilizing the consultation services of the pediatric orthopedist on call physician available to review the images and confirm the fracture for Patient #16.

Based on review of the Emergency Department (ED) Central Log, medical record review, review of physician on-call schedules, and interviews, the facility failed to provide stabilizing treatment for one patient (Patient #16) who presented to the ED on two separate occasions with complaints of pain and swelling to the right ankle, for one of 30 ED patients reviewed.

The findings include:

Review of the facility's ED central log revealed Patient #16 presented to the ED for treatment on 12/25/2021 and 12/27/2021.

Medical record review revealed Patient #16 presented to the ED on 12/25/2021 with complaints of pain and swelling in her right foot and abrasions to her right foot.

Medical record review of the Emergency Room Medical Note dated 12/25/2021 at 11:22 PM revealed, "...Chief complaint: 'She twisted her right ankle, got the dogs leash wrapped around it'...The patient is a 3 ½ year old female who presents to the ER [Emergency Room] today with her father for complaints of pain and swelling to her right ankle and abrasions to her right foot...she sustained abrasions to the dorsum of her right foot. She has been refusing to bear weight since the injury occurred at 6:00 pm..."

Medical record review of diagnostic testing dated 12/25/2021 at 11:20 PM revealed, "...XR [x-ray] foot right...findings: There is no evidence of fracture or other bony abnormality...impression: No acute finding of the right foot...XR ankle right...findings: There is no evidence of fracture of other bony abnormality. The growth plates are within normal limits. No soft tissue abnormality...Impression: normal...XR Tib [tibia] fib [fibula]...findings: there is no evidence of fracture or other bony abnormality. Impression: No acute finding of the right tibia/fibula..."

Patient #16 was discharged from the ED on 12/25/2021 at 11:48 PM with diagnosis of right ankle sprain and right foot abrasions.

Review of Patient #16's Activity Restrictions or Additional Instructions dated 12/25/2021 at 11:48 PM revealed, "...wash the abrasion with soap and water once a day and apply antibiotic ointment once a day...keep covered with band aid while healing...elevate above the level of the heart to reduce pain and swelling. Apply ice over the right ankle 5 to 10 minutes every 1 to 2 hours while awake to reduce pain and swelling...Children's ibuprofen 9 ml [milliliters] by mouth every 6 hours with food for 3 days to reduce pain and inflammation...see her primary care provider on Tuesday December 28th for recheck if she is not improving or if she is still refusing to bear weight..."

Review of the December 2021 physician on call schedule for the ED revealed there was an orthopedic physician available for consult on 12/25/2021.

Medical record review revealed the on-call orthopedic physician was not consulted for Patient #16 on 12/25/2021.

Medical record review revealed Patient #16 presented back at the ED on 12/27/2021 with complaints of continued pain in right foot.

Medical record review of Emergency Room Medical Note dated 12/28/2021 (after midnight) at 5:44 AM revealed, "...Three year 9-month-old female who presents with concerns for right lower extremity pain. Patient was seen here on December 25th for the same complaint...The patient had normal x-rays and was diagnosed with a sprain. She was sent home with supportive care. But mom says patient has continued to complain of pain. Mom brought the patient back for further evaluation. Mom denies any increased swelling, joint redness, or fever. She says that the patient acts like she hurts whenever she goes to walk. She says the patients pain appears to be in her foot..."

Medical record review of diagnostic testing dated 12/27/2021 at 5:07 AM revealed, "...XR tib fib...findings: there is no evidence of fracture or other bony abnormality. Impression: Normal right tibia and fibula...XR foot right...findings: There is no evidence of fracture or other bony abnormality. Impression: Normal right foot..."

Patient #16 was discharged home on 12/28/2021 at 5:51 PM with diagnosis of right lower extremity pain.

Review of Patient #16's Activity Restrictions or Additional Instructions dated 12/28/2021 at 5:51 AM revealed, "...we recommend follow up with the orthopedist if she does not improve. This appointment can be arranged on your own or through her pediatrician's office...in the meantime, she can have ibuprofen childrens syrup 8.5 ml every 6 hours as needed for pain...recheck with her pediatrician in the next couple of days for re-evaluation and to set up the ortho appointment...follow ups...referred to the following specialist for follow-up care: [orthopedist]..."

Medical record review of Hospital B'S Emergency Department (ED) note dated 1/1/2022 at 12:01 AM revealed, "...presents with mother who states her right foot got caught on a dog leash on Christmas Day and was seen at [Hospital A] and had a negative x-ray and then went back a couple of days ago and had another x-ray that was again negative but child is still very hesitant to put weight on her foot so came here for another opinion. Mother states she will act normal and appropriate...but was sitting and not walking around does not seem to be bothered unless bearing weight...Due to continued pain will put in splint and advised mother to follow up with orthopedics in 1 week for reevaluation but to stay in the splint and be non-weightbearing. Short leg posterior splint applied..."

Medical record review of Hospital B ED clinical summary dated 1/1/2022 revealed discharge instructions were provided, including follow-up information with orthopedics. Patient #16 was discharged home from Hospital B on 1/1/2022 at 1:30 AM.

Medical record review of Patient #16's orthopedic follow up on 1/6/2022 at 2:40 PM revealed, "...chief complaint: [Patient #16] comes in today with mother with complaints of right leg injury. Apparently back on Christmas Day, she tripped over the dog leash, twisting her leg. She was seen at [Hospital A] where x-rays were done of the tibia and foot. She was sent home. Mother states she continued in pain, went back to [Hospital A] on the 28th, where x-rays were done again. Again, they did not see a fracture, so she was sent home. Mother then took her to [Hospital B] where they did x-rays and decided to put her in a posterior splint. She has been comfortable in the splint...AP [anterior posterior] and lateral [x-rays] done of the right tibia at [Hospital A] on [12/25/2021], read by me today [orthopedist] show a nondisplaced oblique fracture of the mid to distal tibial shaft...I have told the mother this is a classic toddler's fracture. They are very hard to see on plain x-ray. Treatment will be to put her into a weightbearing short leg cast. I will see her back in 2 weeks..."

Interview with the Director of Quality and Patient Safety on 1/25/2022 at 11:25 AM, revealed the findings of the pediatric orthopedist acknowledged the type of fracture was difficult to identify on x-ray, but that given the history of trauma and altered gait, he would have recommended a splint with an orthopedic follow up.

Interview with the Medical Director of Emergency Department on 1/26/2022 at 10:46 AM revealed, "...I looked at the medical records with both visits and the images. The difference with orthopedics with a 3-year-old is the open growth plates...fractures with that age are sometimes radiographically normal and those aren't able to be diagnosed until clinical follow up...a lot are diagnosed because they don't get better over time or begin bearing weight. Occult fracture is what it's called and that is why [Physician's Assistant] referred them to orthopedics after the return visit to the ER. The evaluation and the care and in hindsight looking back you could say you could have splinted on that second visit... "

The facility failed to provide stabilizing treatment for Patient #16 on 12/25/2021 and 12/27/2021 by not providing a splint and instruction to be non-weight bearing until seen by a pediatric orthopedist.