HospitalInspections.org

Based on a review of facility documentation and medical records (MR) and staff interviews (EMP), it was determined that the facility failed to order diagnostic tests on the correct part of the body identified as be injured for one of 30 medical records reviewed. (MR1).

Findings included:

1) Review of ambulance trip sheet dated January 15, 2017 at 23:22 revealed "...Full blanket lift from bed to cot. during transfer, pt's (patient's) right elbow got caught on transfer from bed to cot, pinning...right arm under...back in an uncomfortable/painful position. Arm was immediately corrected/repositioned out from under pt. in anatomical position. Pt. did start moaning at this point and didn't stop during transport...ED (Emergency Room) staff was informed on pt's right arm to evaluate..."

2) Review of MR1's ER Result Details documented by triage RN EMP5 on January 15, 2017, at 10:50PM revealed "...Focused assessment ER: Pt. sent in from [Skilled Nursing Facility] for reported unresponsive episode. Pt. arrives to the ER moaning. EMS (Emergency Medical Service) states [MR1] has been doing this since...right elbow got caught under [MR1] during transfer form (sic) his bed..."

3) Review of ED Evaluation Final Report completed by EMP4 dated January 15, 2017, at 11:11 PM revealed "...History of Present Illness...Quadriplegic (paralysis of all four limbs)...The patient does not give any information. The patient was sent to the emergency room because the nursing home said that (MR1) was found unresponsive. According to the medics his elbow was caught in the railing of the bed..." As noted EMP4 failed to idenitfy which elbow (right or left) was caught.

4) Review of radiology diagnostic testing that was ordered in the ER on January 15, 2017, at 11:42 PM revealed a single view of left shoulder and elbow which revealed "...there is no acute fracture, dislocation, or traumatic malalignment on these single views of the left elbow and shoulder..." but there was no diagnostic test ordered to evaluate the injury that was reported by EMS staff to the ER of the right elbow and shoulder.

5) Subsequently, the fracture to the right shoulder was not definitively diagnosed until MR1 was transferred back to the hospital from the nursing home on January 25, 2017, secondary to the patient experiencing an altered state of consciousness. Review of Diagnostic Imaging results dated January 25, 2017, at 6:55 AM reveled "...A comminuted fracture of the right proximal humerus is present..."

During interview March 3, 2017, at approximately 9:30 AM EMP1 confirmed the above findings and revealed "...we missed it..."