HospitalInspections.org

Based on interview and record review the facility failed to provide an on-call physician for evaluation (orthopedic consultation) and a complete medical screening examination and evaluation within its service capability for 2 out of 10 sample patients (SP#1and #11).
(2404 and 2409)

Based on interviews and review of medical records, policies and procedures, Medical Staff By-Laws, on-call schedules, Hospital License, Medical Staff Roster, Delineation of Privileges, it was determined the facility failed to provide an on-call physician for evaluation (orthopedic consultation) within its service capability for 2 out of 10 sample patients (SP#1 and #11).


The findings:

The policy "Patient Rights and Organizational Ethics" effective 11/13/14 state if an individual comes to the Emergency department: The hospital will provide an appropriate medical screening examination within the capability of the hospital's dedicated emergency department , including ancillary services routinely available, to determine whether or not an emergency medical condition exists ; and (B.)the hospital will; provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as required to stabilize the emergency condition, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. The hospital will maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individual who have an emergency medical condition.

Review of the facility's policy titled, "EMTALA," effective date 11/13/14, showed that the hospital will maintain a list of physician from its medical staff who are on call for duty after the medical screening examination to provide further medical examination and treatment necessary to stabilize individuals who have been found to have an emergency medical condition. The policy also stated that if the physician on the on-call list is called by the emergency department to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the Hospital Medical Staff's by-laws. If the physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient.

Review of the medical staff bylaws, "Rules And Regulations Of The Medical Staff" documents that when call is placed from the E.R. (emergency Room) for admission or consultation, the physician on call for the E.R. is the one responsible to come in. The physician immediately following the one on-call shall be considered second on-call. The physician on second call has a responsibility for response and coverage equal to that of the first call.

Review of the facility's policy section: Medical Staff - Policy for Taking Emergency Room Call-Main campus dated 02/18/2015-states for patients requiring transfer to a higher level of care hospital (must be the patient's choice): If the service is on the hospital's license, the physician on-call must present to the emergency room for secondary evaluation.


1) Record review of the (Emergency Department) ED physician notes by the physician assistance (ED- PA) dated 12/17/2016 showed sampled patient (SP) #1 a self-pay who presented to the ED with complaint of hand pain. The patient reports injury that affects the right hand diffusely. The injury was sustained at home, the result of a fight. Patient stated he punched a person on the teeth yesterday. The symptoms/episode began/occurred yesterday and the symptoms are aggravated by movement. Stable vital signs (VS) and no hemodynamically instability.


Review of SP#1 medical record dated on 12/17/16 showed a timeline as follow:
At 8:26 PM, Order for specialty orthopedic consult with MD-A.
At 9:20 PM, PA (Physician Assistant) spoke to orthopedic (surgeon) consult MD-A and she stated she will be coming to see patient before midnight.
At 9:22 PM, the Transition of Care: care is transferred to ED physician MD-C after detail discussion of the patient's case.
At 11:08 PM, the blood pressure (BP)-133/74, pulse (P)-62, respiration (R)-18, O2 saturation (SpO2) -99% and pain 6 out of 10.
At 11:10 PM, medication administration of Clindamycin 600mg Intravenous (IV) antibiotic.
At 11:27 PM, medication administration of Morphine 4mg IV for pain.
At 00:45 AM, on 12/18/16 patient transferred in stable condition by emergency medical services (EMS) ground to hospital #2 with copy of medical records and copy of x-rays.

Phone interview on 1/19/17 at 2:34 PM with the orthopedic surgeon (MD-A), stated that she was on call on 12/17/16 and she recalls it was a human mouth injury to the hand from a fight and reviewed the case telephonically with the ED physician MD-C. She notified the ED physician MD-C that she does not cover hand injuries and that the human bite was an emergency. She did offer to come that evening but when she called in route to the hospital the patient was transferred out.

December's Q4 2016 Orthopedic Surgery ER Call Schedule showed that orthopedic surgeon (MD-A) was on-call on 12/17-18/2016.

SP #1 medical record does not show a consultation report from the orthopedic surgeon (MD-A) consulted.
Further record review showed no documentation regarding the orthopedic consultation in the emergency department with (ED) physician (MD-C).

Interview with Chief Nursing Officer (CNO) on 12/20/17 on 11:53 AM confirmed above findings that there were no documentation regarding consultation from the orthopedic surgeon and ED physician, MD-C in SP #1 medical record.

Review of the hospital's license (effective 01/11/2017) showed that orthopedics is listed as one of the hospital dedicated emergency department emergency services.

The medical staff roster for orthopedic surgeons revealed all five active staff surgeons including orthopedic surgeon MD-A were approved for core privileges in Orthopedic Surgery which include admission, work up and providing nonsurgical and surgical care to patients to correct or treat various acute and chronic conditions, illness or injuries of the musculoskeletal system, including the provision of consultation.

The policy subject: "Policy for Taking Emergency Room Call- Main Campus" (dated 02/18/2015) state that the patient requiring transfer to a higher level of care hospital (must be patient's choice): if the service is on the hospital's license, the physician on-call must present to the emergency room for secondary evaluation. The hospital did not follow its policy.


Sampled patient SP #1 medical records from the receiving hospital (#2) showed that he was received in the ED on 12/18/2016 at 01:34 AM. The ED physician notes showed SP #1 presented with swelling to the right hand. He is s/p (status post) a fight bite 7 days ago. The Differential diagnosis: cellulitis, abscess. Radiology results: X-ray, hand, no acute fracture or malalignment. On 12/18/2016 at 06:28 AM was seen by Ortho (Orthopedic Specialist). No surgical intervention required. Recommend admit to medicine with ortho follow up, IV (intravenous) clindamycin (antibiotics) given.


According to SP #1 History and Physical (dictated 12/19/2016) showed the plan of care: OR (surgery) for the right hand and small finger irrigation and debridement and possible tendon repair and all other indicated procedures. Patient will continue IV antibiotics.


The operative report dated 12/20/2016 showed SP #1 had an irrigation and debridement including bone of right small finger open metacarpal head fracture. An open treatment of the right small finger metacarpal head fracture, and a repair of the ulnar sagittal band, right small finger.

On 12/21/2016, the "Discharge Summary" noted that the orthopedics hand service performed a right small arthrotomy (an opening in a joint that may be used in drainage) and placed a cast. SP #1 completed 4 days of antibiotic therapy. The patient was discharged as per his persistence prior to completing the recommended 7 days of antibiotic therapy. Throughout the stay and at discharge, the patient was hemodynamically stable, afebrile and without signs of systemic involvement.

Phone interview on 2/21/2017 at 12:45 pm with the ED Physician/MD-C regarding SP #1 he stated that the patient came in with an infected right hand; there was a puncture mark from another human's mouth. Patient did not have a fresh wound. Patient has an infected hand where it can get worse; We do not want to delay the care and treatment; we need to make sure we send patient to a facility with a hand specialist. Further interview revealed that a consult with the orthopedic surgeon was called; however, she does not have delineation to perform hand surgery. Physician/MD-C stated "We do not force the orthopedic to come in. Consultation can be made telephonically. She does not have to come in. Furthermore, he stated: "I am aware I made no documentation."

Phone interview with the on-call orthopedic surgeon Physician/MD-A on 2/22/2017 at 9:45 am revealed that she barely remembers the details of the case; she remembers talking to PA-B and ED Physician/MD-C for SP #1. The patient had swelling and redness on the right hand. From the report, it sounds like a fight bite. I made the decision to send the patient to a facility with certified hand surgeon, with extensive experience. There is risk of the infection getting worse and the threat of loss of function of the right hand due to the complexity of the injury. This facility never hired a hand surgeon. Currently, it has been clarified that on call orthopedic surgeons do not have delineation to do hand surgery. We refer them to hand specialists; we do not have delineation to perform hand surgery. In conclusion, she stated the transfer to facility #2 was appropriate. The hospital was equipped to with staff (orthopedic surgeon on-call) and services or equipment. Necessary to stabilize Patient #1's emergency medical condition prior to transferring the patient on 12/17/2017. The Orthopedic surgeon failed to come in timely to evaluate as care was delayed for 4 hours.



On 2/23/17 at 5:00 pm reviewed again the hospital's website. Navigated the hospital website and search through home - services - physician/provider - orthopedic - hand surgeon and found search results for 3 names of physicians. Physician K (a plastic surgeon), Physician L (a general surgeon), and Physician M ( a surgeon of the hand).

On 2/23/17 at 5:30 pm Called and spoke with the Hospital Compliance/Privacy Officer and asked whether the hospital website is updated. Provided the names of the physicians found on the search results.

Phone interview on 2/24/2017 at 10:44 am with Hospital Compliance/Privacy Officer who said that the hospital website was not updated. She stated the they have corrected the website already and removed the name of Physician L as he has no privileges to do hand and is a general surgeon part of the medical staff. At the Off Campus Facility located at Broward County - Physician K is a plastic surgeon, fairly new, approved medical staff under FPPE, and has not done anything or show any contacts at Off Campus Facility. What happens is they do a lot in their office procedures and in their office when a pt. needs to be brought to the hospital and that is for their outpatient services and they need to be affiliated to the hospital to where they can bring the pt., if in case the pt. requires to go to a hospital from their ambulatory surgical center.

He does hand but has no hand cases at the (other hospital) Off Campus Facility (located at Broward County) or this hospital, only will get active status if he has done any contacts. Physician K is still on FPPE. Physician K is a plastic surgeon and not an orthopedic, and is not part of the on-call list. Physician M has privileges at the Off Campus Facility but not at this hospital. He has not done a procedure or not come in to the hospital. If in case he will bring cases +to the hospital, the AOC has to be informed and the Medical Staff Services to allow him to come in. Physician M does hand and is an active medical staff at the Off Campus Facility at Broward but not at the hospital. Physician M is only privilege on the Off Campus Facility. We know they are schooled because of the information from the Off Campus Facility. If in case a pt. is brought in at the hospital/Facility #1, we can let them do the case but they have to go through the AOC and chief of staff to have them bring pt. in.

Reviewed the delineation of privileges of Physician K showed is a provisional staff for Plastic Surgery.
Review of Physician M credentials showed his reappointment as an Active staff would start on 3/21/2017 for the hospital and at the Off Campus Facility of the hospital.

Review of the hospital's medical staff "Roster by Specialty" showed Physician M (a general surgeon) listed under "surgery of the hand". His status is active.
Also listed is Physician K (a plastic surgeon), and Physician L (a general surgeon). The roster list 10 (ten) orthopedic surgeons.




2) Review of sample patient (SP) #11 medical record revealed she came by ambulance to the Emergency Department (ED) on 1/31/17 with complaints of right leg pain, and right hand swelling. Patient (Pt.) previous history showed she is a homeless and uninsured.

The (HPI) History of the present illness authored by the Nursing Practitioner (NP) on 1/31/17 revealed that there is cellulitis of the right hand, lateral aspect of the right calf, medial aspect of the right calf and right shin. It is erythematous swollen, warm, and began 2 weeks ago. The possible cause of this is "skin popping and drug abuse". The symptoms are aggravated by movement and pt. has not been seen by a physician recently.


The Physical Examination at 11:21 am revealed that there is limited passive range of motion in the right hand and limited active ROM to the right leg due to the pain. The circulation and sensation is intact on all extremities. There is presence of lesions and scabs from IV drug abuse on the right hand and right leg. The right hand has minimal movement on extension position with minimal flexion to the right fingers and wrist indicating a tenosynovitis.

The review of the X-ray of the right hand revealed no fracture or dislocation. There is soft tissue swelling. No soft tissue mass or abnormal calcifications are seen. Linear 7 mm density seen along the dorsal aspect of the forearm. A foreign body in this region cannot be excluded and clinical correlation is needed. X-ray of the tibia/fibula (right leg) showed no acute fracture or dislocation. Soft tissue swelling, No definite findings of osteomyelitis to the right leg. The laboratory test showed a critical lab value for lactic acid of 2.3. (Normal range- 0.5-1.0; CRITICAL value 2.0mmo/L or greater).

Intravenous (IV) antibiotics: Zosyn 3.375mg IV, and Vancomycin 1 gram IV was administered. IV Fluid bolus of normal saline, and pain medication Toradol 30mg IV was also administered.

The care of SP#11 was collaborated between the Nurse Practitioner and the Emergency Department Physician (Physician B) that agreed with the examination and findings of the pt. Differential diagnosis showed Cellulitis, Tenosynovitis of the right hand, cellulitis of the right hand and right leg. A physician consult was called. Physician G, an orthopedic surgeon was called and the case was presented. It is noted on the record review that as per Physician G (orthopedic surgeon), the pt. requires a hand specialist and (name of the hospital) has no hand specialty for tenosynovitis and would require a transfer to a facility with such subspecialty in the best interest of the pt.

SP #11 ED orders dated 01/31/2017 at 13:08 PM showed a consult was orders for physician G (orthopedic surgeon). Review SP #11 ED physician notes dated 01/31/2017 at 13:09 PM showed a physician consultation [named orthopedic surgeon] per nursing supervisor ortho (orthopedic) needs to come in and evaluate and document reason for transfer. At 13:36 PM physician consultation: [named orthopedic surgeon] physician G was contacted at 13:36, regarding admission, consult, per [named orthopedic surgeon] physician G patient requires a hand specialist. The hospital has no hand specialty for tenosynovitis and would require a transfer to a facility with such sub specialty in the best interest of the patient. It is not necessary for physician G to come in to evaluate the patient.

Sampled patient#11 ED disposition notes showed on 01/31/2017 transfer ordered to trauma/neuro facility. Diagnosis are Tenosynovitis of hand-wrist-right with foreign body, cellulitis of leg-right, drug abuse, sepsis. At 14:23 the ED physician notes showed that I explained to patient also with elevated WBC (white blood count) and bandemia with elevated lactic acid, requiring admission for IV (intravenous) ABX( antibiotics). ED course: transfer to be evaluated by hand a surgeon to rule out tenosynovitis/osteomyelitis and also retained foreign body.

Interview with the ED Physician (Physician B) on 2/21/2017 at 11:10 am , the physician recalls SP#11 and that the care was collaborative between her and the nurse practitioner. She stated that the pt has tenosynovitis with a foreign body to the hand. Physical exam was performed with diagnostic tests, IV antibiotics, pain medicine, fluids for elevated lactate, and splint to the hand was provided as treatment at ED. An orthopedic consult was called and she discussed with the ortho consult (Physician G) about the case of the pt. and it was determined that a hand surgeon is needed to determine whether to do surgery or not, to the hand, and also to address the infection. During the discussion over the phone with the orthopedic consult, he cannot handle the hand because it was out of his scope of practice. It was agreed to transfer the pt. who needed to see urgently the hand surgeon and delaying or keeping the pt. without being seen by the hand surgeon can cause the pt. to lose function of the hand or even worst an amputation. Tenosynovitis (inflammation of the lining of the sheath that surrounds a tendon) is a medical emergency. The Administrator in Charge (AOC) was aware of the need to transfer the pt. She discussed with the physician of the receiving facility the pt.'s case and it was accepted. The pt. was stable for transfer and appropriate transport arrangements were done.

On 1/31/17 at 2:23 pm, Physician B presented the case to the physician of the receiving facility and the concern for a foreign body to the dorsum of the right wrist possibly a retained needle since the pt. is an IV drug abuser. Pt assessment, treatment provided at ED, and the care of the pt. requiring a hand surgeon to evaluate for tenosynovitis and deeper infection with retained foreign body with an unknown amount of time was presented.

A signed pt. consent to transfer was noted and witnessed on 1/31/17. The pt. was accepted at the receiving facility, appropriate transportation with a Basic Life Support ambulance, and copies of documents were provided. Report between the nurses of the receiving and transferring facility was done prior to transfer. Pt was transferred to the receiving facility on 1/31/017 at 4:16pm at a stable condition. Vitals signs at transfer showed BP(blood pressure) 131/76, Pulse 75, Respirations 18, pulse ox 99% on room air, pain of 0.

Review of the Patient Transfer to Another Hospital form showed Diagnosis: Tenosynovitis of hand -wrist, and cellulitis of the leg. The transfer reason was the hospital was unable to -the needed services and the pt. consents for the transfer. Name of the AOC was indicated, and the form was signed by Physician B.

During the phone interview with Physician G - orthopedic surgeon on 2/21/2017 at 10:10 am, the surgeon said he performs musculoskeletal surgery with subspecialty to sports medicine, and does not perform hand surgery. He further stated that he has not managed a tenosynovitis case before and does not manage tenosynovitis. He vaguely recalls SP#11. He stated a case of an infected hand with a foreign body. The pt. with the hand infection can rapidly progress and compromise the hand. He recalls discussion of the treatment that requires a hand surgeon and the plan to transfer the pt. to a center with a hand surgeon. The case was limb threatening and he does not have the expertise to treat this pt. He further stated that the ED has provided appropriate treatment and that the pt. requires the expertise and a surgical management of a hand surgeon. He further stated does not know of a hand surgeon that works at Facility 1.

Phone interview with the nurse practitioner (NP) on 2/22/17 at 10:10 am revealed she worked as an ARNP for 19 years. SP#11 was seen at ED and collaborated the care with the ED physician from the beginning of pt care. The ED Physician also saw and evaluated the pt. Pt. was an IV drug abuser and is "skin popping". Heroine is injected using needle and syringe underneath the skin to which it creates cellulites on areas of the skin that extended to the legs. There was a foreign body on xray of the hand. The right hand was swollen and unable to move. An orthopedic consult was called and discussed the physical assessment of the pt., test results, and treatment provided and diagnosis of tenosynovitis. During the discussion, the pt. needed the expertise of the hand surgeon who have the expertise to intervene to the hand that also have an infection. The orthopedic consult did not have the expertise to intervene or do something to the hand of SP#11. The ED physician was aware and agreed that the pt. needed to be transferred to a facility with a hand surgeon. The nursing supervisor and AOC was aware who also spoke with the orthopedic consult.

The interview with the Director of Nursing Support Services on 2/21/2017 at 10:00 am revealed that all ED pts. that requires to be transferred out, she is made aware to make sure that the hospital does not really have the services that the pt. need and the transfer is escalated to the AOC. SP#11 case was addressed by the AOC and who spoke with the ED physician who ensured that the hospital don't have the services for the pt. It was OK for the AOC to transfer the pt.

Interview with the CNO at 12:01pm of 2/21/2017 who was the Administrator on Call (AOC) and was aware of the transfer of SP#11. The pt. was evaluated by both the NP(Nurse Practitioner) and the ED physician. He further stated that he spoke with the orthopedic surgeon who said was unable to perform procedure to the pt. and pt. need to see hand surgeon to do a surgery to explore the hand soon. There is a foreign body on the hand and it will compromise the hand and pt. have an infection too. The CNO authorized the transfer. Closest facility is the receiving
Facility that have hand surgeon. CNO further stated there are no physician with privileges at the facility for hand surgery.

Interview with the ED Medical Director on 2/20/17 at 4:30 pm revealed that for a tenosynovitis the pt. digits are swollen, and is unable to flex and extend, and cause pain to any movement always secondary to an infection. ED diagnostics include x-rays, laboratory, wound assessment, and pain medication Treatment at ED would include IV antibiotics, identifying the cause, clean the wound if open, immobilization using a splint to protect the hand, and then consultation with a hand surgeon. The hand surgeon can wash out and drain the hand. The care would require a transfer to a facility with a hand surgeon to the nearest facility and explain to the pt. to make decisions and choose which of 2 hospitals nearby for treatment by a hand surgeon.

Interview of Staff A on 2/20/17 at 2:15pm revealed that she recalls SP#11 was evaluated by both the NP and Physician B. She further stated that pt. came with cellulitis of the right hand and leg, and has history of skin popping and describes drug users unable to find veins will inject the drug under the skin. She recalls that both the NP and Physician B was at the bedside. Physician B saw the pt. and discussed with the pt. the transfer to which the pt. agreed for the transfer. She recalls that Physician B said that the pt. needs a hand specialist. She further described the transfer process and recalls giving report to the nurse at the receiving facility. Staff A described her responsibilities on assessments, monitoring, and making sure orders and treatments are given as ordered.


Medical records were reviewed for patients who presented to the hospital for similar complaints related to patient #1 and #11. The review revealed that a patient presented to the ED with a bite by a bee on 09/01/2016. An orthopedic consult was requested for the named orthopedic surgeon (physician I). The Orthopedic consultation was completed and the assessment was an acute infectious tenosynovitis. The patient was then transferred to another facility. Review of another sampled patient medical record showed that he presented to the ED and was diagnosed with a hand laceration; neurovascular/ tendon injury to the right hand. ED course showed the nurse administrator stated per policy, transfer process cannot be initiated until he has been seen by Ortho (orthopedic) on call. Dr. [named] orthopedic surgeon (physician I) paged. A physician consultation was completed by the orthopedic surgeon and transfer was made for hand evaluation.

Based on interview and record review the facility failed to provide a complete medical screening examination and evaluation (orthopedic consultation) within its service capability prior to transfer for 2 out of 10 sample patients (SP#1 and #11).


The findings:
The policy "Patient Rights and Organizational Ethics" effective 11/13/14 state if an individual comes to the Emergency department: The hospital will provide an appropriate medical screening examination within the capability of the hospital's dedicated emergency department , including ancillary services routinely available, to determine whether or not an emergency medical condition exists ; and (B.)the hospital will; provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as required to stabilize the emergency condition, or arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. The hospital will maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individual who have an emergency medical condition.

Review of the facility's policy titled, "EMTALA," effective date 11/13/14, showed that the hospital will maintain a list of physician from its medical staff who are on call for duty after the medical screening examination to provide further medical examination and treatment necessary to stabilize individuals who have been found to have an emergency medical condition. The policy also stated that if the physician on the on-call list is called by the emergency department to provide emergency screening or treatment, the physician must respond within a reasonable time in accordance with the time established in the Hospital Medical Staff's by-laws. If the physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the emergency patient.

Review of the medical staff bylaws, "Rules And Regulations Of The Medical Staff" documents that when call is placed from the E.R. (emergency Room) for admission or consultation, the physician on call for the E.R. is the one responsible to come in. The physician immediately following the one on-call shall be considered second on-call. The physician on second call has a responsibility for response and coverage equal to that of the first call.

Review of the facility's policy section: Medical Staff - Policy for Taking Emergency Room Call-Main campus dated 02/18/2015-states for patients requiring transfer to a higher level of care hospital (must be the patient's choice): If the service is on the hospital's license, the physician on-call must present to the emergency room for secondary evaluation.


1) Record review of the (Emergency Department) ED physician notes by the physician assistance (ED- PA) dated 12/17/2016 showed sampled patient (SP) #1 a self-pay who presented to the ED with complaint of hand pain. The patient reports injury that affects the right hand diffusely. The injury was sustained at home, the result of a fight. Patient stated he punched a person on the teeth yesterday. The symptoms/episode began/occurred yesterday and the symptoms are aggravated by movement. Stable vital signs (VS) and no hemodynamically instability.


Review of SP#1 medical record dated on 12/17/16 showed a timeline as follow:
At 8:26 PM, Order for specialty orthopedic consult with MD-A.
At 9:20 PM, PA (Physician Assistant) spoke to orthopedic (surgeon) consult MD-A and she stated she will be coming to see patient before midnight.
At 9:22 PM, the Transition of Care: care is transferred to ED physician MD-C after detail discussion of the patient's case.
At 11:08 PM, the blood pressure (BP)-133/74, pulse (P)-62, respiration (R)-18, O2 saturation (SpO2) -99% and pain 6 out of 10.
At 11:10 PM, medication administration of Clindamycin 600mg Intravenous (IV) antibiotic.
At 11:27 PM, medication administration of Morphine 4mg IV for pain.
At 00:45 AM, on 12/18/16 patient transferred in stable condition by emergency medical services (EMS) ground to hospital #2 with copy of medical records and copy of x-rays.

Phone interview on 1/19/17 at 2:34 PM with the orthopedic surgeon (MD-A), stated that she was on call on 12/17/16 and she recalls it was a human mouth injury to the hand from a fight and reviewed the case telephonically with the ED physician MD-C. She notified the ED physician MD-C that she does not cover hand injuries and that the human bite was an emergency. She did offer to come that evening but when she called in route to the hospital the patient was transferred out.

December's Q4 2016 Orthopedic Surgery ER Call Schedule showed that orthopedic surgeon (MD-A) was on-call on 12/17-18/2016.

SP #1 medical record does not show a consultation report from the orthopedic surgeon (MD-A) consulted.
Further record review showed no documentation regarding the orthopedic consultation in the emergency department with (ED) physician (MD-C).

Interview with Chief Nursing Officer (CNO) on 12/20/17 on 11:53 AM confirmed above findings that there were no documentation regarding consultation from the orthopedic surgeon and ED physician, MD-C in SP #1 medical record.

Review of the hospital's license (effective 01/11/2017) showed that orthopedics is listed as one of the hospital dedicated emergency department emergency services.

The medical staff roster for orthopedic surgeons revealed all five active staff surgeons including orthopedic surgeon MD-A were approved for core privileges in Orthopedic Surgery which include admission, work up and providing nonsurgical and surgical care to patients to correct or treat various acute and chronic conditions, illness or injuries of the musculoskeletal system, including the provision of consultation.

The policy subject: "Policy for Taking Emergency Room Call- Main Campus" (dated 02/18/2015) state that the patient requiring transfer to a higher level of care hospital (must be patient's choice): if the service is on the hospital's license, the physician on-call must present to the emergency room for secondary evaluation. The hospital did not follow its policy.


Sampled patient SP #1 medical records from the receiving hospital (#2) showed that he was received in the ED on 12/18/2016 at 01:34 AM. The ED physician notes showed SP #1 presented with swelling to the right hand. He is s/p (status post) a fight bite 7 days ago. The Differential diagnosis: cellulitis, abscess. Radiology results: X-ray, hand, no acute fracture or malalignment. On 12/18/2016 at 06:28 AM was seen by Ortho (Orthopedic Specialist). No surgical intervention required. Recommend admit to medicine with ortho follow up, IV (intravenous) clindamycin (antibiotics) given.


According to SP #1 History and Physical (dictated 12/19/2016) showed the plan of care: OR (surgery) for the right hand and small finger irrigation and debridement and possible tendon repair and all other indicated procedures. Patient will continue IV antibiotics.


The operative report dated 12/20/2016 showed SP #1 had an irrigation and debridement including bone of right small finger open metacarpal head fracture. An open treatment of the right small finger metacarpal head fracture, and a repair of the ulnar sagittal band, right small finger.

On 12/21/2016, the "Discharge Summary" noted that the orthopedics hand service performed a right small arthrotomy (an opening in a joint that may be used in drainage) and placed a cast. SP #1 completed 4 days of antibiotic therapy. The patient was discharged as per his persistence prior to completing the recommended 7 days of antibiotic therapy. Throughout the stay and at discharge, the patient was hemodynamically stable, afebrile and without signs of systemic involvement.

Phone interview on 2/21/2017 at 12:45 pm with the ED Physician/MD-C regarding SP #1 he stated that the patient came in with an infected right hand; there was a puncture mark from another human's mouth. Patient did not have a fresh wound. Patient has an infected hand where it can get worse; We do not want to delay the care and treatment; we need to make sure we send patient to a facility with a hand specialist. Further interview revealed that a consult with the orthopedic surgeon was called; however, she does not have delineation to perform hand surgery. Physician/MD-C stated "We do not force the orthopedic to come in. Consultation can be made telephonically. She does not have to come in. Furthermore, he stated: "I am aware I made no documentation."

Phone interview with the on-call orthopedic surgeon Physician/MD-A on 2/22/2017 at 9:45 am revealed that she barely remembers the details of the case; she remembers talking to PA-B and ED Physician/MD-C for SP #1. The patient had swelling and redness on the right hand. From the report, it sounds like a fight bite. I made the decision to send the patient to a facility with certified hand surgeon, with extensive experience. There is risk of the infection getting worse and the threat of loss of function of the right hand due to the complexity of the injury. This facility never hired a hand surgeon. Currently, it has been clarified that on call orthopedic surgeons do not have delineation to do hand surgery. We refer them to hand specialists; we do not have delineation to perform hand surgery. In conclusion, she stated the transfer to facility #2 was appropriate.



On 2/23/17 at 5:00 pm reviewed again the hospital's website. Navigated the hospital website and search through home - services - physician/provider - orthopedic - hand surgeon and found search results for 3 names of physicians. Physician K (a plastic surgeon), Physician L (a general surgeon), and Physician M ( a surgeon of the hand).

On 2/23/17 at 5:30 pm Called and spoke with the Hospital Compliance/Privacy Officer and asked whether the hospital website is updated. Provided the names of the physicians found on the search results.

Phone interview on 2/24/2017 at 10:44 am with Hospital Compliance/Privacy Officer who said that the hospital website was not updated. She stated the they have corrected the website already and removed the name of Physician L as he has no privileges to do hand and is a general surgeon part of the medical staff. At the Off Campus Facility located at Broward County - Physician K is a plastic surgeon, fairly new, approved medical staff under FPPE, and has not done anything or show any contacts at Off Campus Facility. What happens is they do a lot in their office procedures and in their office when a pt. needs to be brought to the hospital and that is for their outpatient services and they need to be affiliated to the hospital to where they can bring the pt., if in case the pt. requires to go to a hospital from their ambulatory surgical center.

He does hand but has no hand cases at the (other hospital) Off Campus Facility (located at Broward County) or this hospital, only will get active status if he has done any contacts. Physician K is still on FPPE. Physician K is a plastic surgeon and not an orthopedic, and is not part of the on-call list. Physician M has privileges at the Off Campus Facility but not at this hospital. He has not done a procedure or not come in to the hospital. If in case he will bring cases to the hospital, the AOC has to be informed and the Medical Staff Services to allow him to come in. Physician M does hand and is an active medical staff at the Off Campus Facility at Broward but not at the hospital. Physician M is only privilege on the Off Campus Facility. We know they are schooled because of the information from the Off Campus Facility. If in case a pt. is brought in at the hospital/Facility #1, we can let them do the case but they have to go through the AOC and chief of staff to have them bring pt. in.

Reviewed the delineation of privileges of Physician K showed is a provisional staff for Plastic Surgery.
Review of Physician M credentials showed his reappointment as an Active staff would start on 3/21/2017 for the hospital and at the Off Campus Facility of the hospital.

Review of the hospital's medical staff "Roster by Specialty" showed Physician M (a general surgeon) listed under "surgery of the hand". His status is active.
Also listed is Physician K (a plastic surgeon), and Physician L (a general surgeon). The roster list 10 (ten) orthopedic surgeons.




2) Review of sample patient (SP) #11 medical record revealed she came by ambulance to the Emergency Department (ED) on 1/31/17 with complaints of right leg pain, and right hand swelling. Patient (Pt.) previous history showed she is a homeless and uninsured.

The (HPI) History of the present illness authored by the Nursing Practitioner (NP) on 1/31/17 revealed that there is cellulitis of the right hand, lateral aspect of the right calf, medial aspect of the right calf and right shin. It is erythematous swollen, warm, and began 2 weeks ago. The possible cause of this is "skin popping and drug abuse". The symptoms are aggravated by movement and pt. has not been seen by a physician recently.


The Physical Examination at 11:21 am revealed that there is limited passive range of motion in the right hand and limited active ROM to the right leg due to the pain. The circulation and sensation is intact on all extremities. There is presence of lesions and scabs from IV drug abuse on the right hand and right leg. The right hand has minimal movement on extension position with minimal flexion to the right fingers and wrist indicating a tenosynovitis.

The review of the X-ray of the right hand revealed no fracture or dislocation. There is soft tissue swelling. No soft tissue mass or abnormal calcifications are seen. Linear 7 mm density seen along the dorsal aspect of the forearm. A foreign body in this region cannot be excluded and clinical correlation is needed. X-ray of the tibia/fibula (right leg) showed no acute fracture or dislocation. Soft tissue swelling, No definite findings of osteomyelitis to the right leg. The laboratory test showed a critical lab value for lactic acid of 2.3 (normal range) .

Intravenous (IV) antibiotics: Zosyn 3.375mg IV, and Vancomycin 1 gram IV was administered. IV Fluid bolus of normal saline, and pain medication Toradol 30mg IV was also administered.

The care of SP#11 was collaborated between the Nurse Practitioner and the Emergency Department Physician (Physician B) that agreed with the examination and findings of the pt. Differential diagnosis showed Cellulitis, Tenosynovitis of the right hand, cellulitis of the right hand and right leg. A physician consult was called. Physician G, an orthopedic surgeon was called and the case was presented. It is noted on the record review that as per Physician G (orthopedic surgeon), the pt. requires a hand specialist and (name of the hospital) has no hand specialty for tenosynovitis and would require a transfer to a facility with such subspecialty in the best interest of the pt.

SP #11 ED orders dated 01/31/2017 at 13:08 PM showed a consult was orders for physician G (orthopedic surgeon)
Review SP #11 ED physician notes dated 01/31/2017 at 13:09 PM showed a physician consultation [named orthopedic surgeon] per nursing supervisor ortho (orthopedic) needs to come in and evaluate and document reason for transfer. At 13:36 PM physician consultation: [named orthopedic surgeon] physician G was contacted at 13:36, regarding admission, consult, per [named orthopedic surgeon] physician G patient requires a hand specialist. The hospital has no hand specialty for tenosynovitis and would require a transfer to a facility with such sub specialty in the best interest of the patient. It is not necessary for physician G to come in to evaluate the patient.

Sampled patient#11 ED disposition notes showed on 01/31/2017 transfer ordered to trauma/neuro facility. Diagnosis are Tenosynovitis of hand-wrist-right with foreign body, cellulitis of leg-right, drug abuse, sepsis. At 14:23 the ED physician notes showed that I explained to patient also with elevated WBC (white blood count) and bandemia with elevated lactic acid, requiring admission for IV (intravenous) ABX( antibiotics). ED course: transfer to be evaluated by hand a surgeon to rule out tenosynovitis/osteomyelitis and also retained foreign body.

Interview with the ED Physician (Physician B) on 2/21/2017 at 11:10 am , the physician recalls SP#11 and that the care was collaborative between her and the nurse practitioner. She stated that the pt has tenosynovitis with a foreign body to the hand. Physical exam was performed with diagnostic tests, IV antibiotics, pain medicine, fluids for elevated lactate, and splint to the hand was provided as treatment at ED. An orthopedic consult was called and she discussed with the ortho consult (Physician G) about the case of the pt. and it was determined that a hand surgeon is needed to determine whether to do surgery or not, to the hand, and also to address the infection. During the discussion over the phone with the orthopedic consult, he cannot handle the hand because it was out of his scope of practice. It was agreed to transfer the pt. who needed to see urgently the hand surgeon and delaying or keeping the pt. without being seen by the hand surgeon can cause the pt. to lose function of the hand or even worst an amputation. Tenosynovitis (inflammation of the lining of the sheath that surrounds a tendon) is a medical emergency. The Administrator in Charge (AOC) was aware of the need to transfer the pt. She discussed with the physician of the receiving facility the pt.'s case and it was accepted. The pt. was stable for transfer and appropriate transport arrangements were done.

On 1/31/17 at 2:23 pm, Physician B presented the case to the physician of the receiving facility and the concern for a foreign body to the dorsum of the right wrist possibly a retained needle since the pt. is an IV drug abuser. Pt assessment, treatment provided at ED, and the care of the pt. requiring a hand surgeon to evaluate for tenosynovitis and deeper infection with retained foreign body with an unknown amount of time was presented.

A signed pt. consent to transfer was noted and witnessed on 1/31/17. The pt. was accepted at the receiving facility, appropriate transportation with a Basic Life Support ambulance, and copies of documents were provided. Report between the nurses of the receiving and transferring facility was done prior to transfer. Pt was transferred to the receiving facility on 1/31/017 at 4:16pm at a stable condition. Vitals signs at transfer showed BP(blood pressure) 131/76, Pulse 75, Respirations 18, pulse ox 99% on room air, pain of 0.

Review of the Patient Transfer to Another Hospital form showed Diagnosis: Tenosynovitis of hand -wrist, and cellulitis of the leg. The transfer reason was the hospital was unable to provided the needed services and the pt. consents for the transfer. Name of the AOC was indicated, and the form was signed by Physician B.

During the phone interview with Physician G - orthopedic surgeon on 2/21/2017 at 10:10 am, the surgeon said he performs musculoskeletal surgery with subspecialty to sports medicine, and does not perform hand surgery. He further stated that he has not managed a tenosynovitis case before and does not manage tenosynovitis. He vaguely recalls SP#11. He stated a case of an infected hand with a foreign body. The pt. with the hand infection can rapidly progress and compromise the hand. He recalls discussion of the treatment that requires a hand surgeon and the plan to transfer the pt. to a center with a hand surgeon. The case was limb threatening and he does not have the expertise to treat this pt. He further stated that the ED has provided appropriate treatment and that the pt. requires the expertise and a surgical management of a hand surgeon. He further stated does not know of a hand surgeon that works at Facility 1.

Phone interview with the nurse practitioner (NP) on 2/22/17 at 10:10 am revealed she worked as an ARNP for 19 years. SP#11 was seen at ED and collaborated the care with the ED physician from the beginning of pt care. The ED Physician also saw and evaluated the pt. Pt. was an IV drug abuser and is "skin popping". Heroine is injected using needle and syringe underneath the skin to which it creates cellulites on areas of the skin that extended to the legs. There was a foreign body on xray of the hand. The right hand was swollen and unable to move. An orthopedic consult was called and discussed the physical assessment of the pt., test results, and treatment provided and diagnosis of tenosynovitis. During the discussion, the pt. needed the expertise of the hand surgeon who have the expertise to intervene to the hand that also have an infection. The orthopedic consult did not have the expertise to intervene or do something to the hand of SP#11. The ED physician was aware and agreed that the pt. needed to be transferred to a facility with a hand surgeon. The nursing supervisor and AOC was aware who also spoke with the orthopedic consult.

The interview with the Director of Nursing Support Services on 2/21/2017 at 10:00 am revealed that all ED pts. that requires to be transferred out, she is made aware to make sure that the hospital does not really have the services that the pt. need and the transfer is escalated to the AOC. SP#11 case was addressed by the AOC and who spoke with the ED physician who ensured that the hospital don't have the services for the pt. It was OK for the AOC to transfer the pt.

Interview with the CNO at 12:01pm of 2/21/2017 who was the Administrator on Call (AOC) and was aware of the transfer of SP#11. The pt. was evaluated by both the NP(Nurse Practitioner) and the ED physician. He further stated that he spoke with the orthopedic surgeon who said was unable to perform procedure to the pt. and pt. need to see hand surgeon to do a surgery to explore the hand soon. There is a foreign body on the hand and it will compromise the hand and pt. have an infection too. The CNO authorized the transfer. Closest facility is the receiving
Facility that have hand surgeon. CNO further stated there are no physician with privileges at the facility for hand surgery.

Interview with the ED Medical Director on 2/20/17 at 4:30 pm revealed that for a tenosynovitis the pt. digits are swollen, and is unable to flex and extend, and cause pain to any movement always secondary to an infection. ED diagnostics include x-rays, laboratory, wound assessment, and pain medication Treatment at ED would include IV antibiotics, identifying the cause, clean the wound if open, immobilization using a splint to protect the hand, and then consultation with a hand surgeon. The hand surgeon can wash out and drain the hand. The care would require a transfer to a facility with a hand surgeon to the nearest facility and explain to the pt. to make decisions and choose which of 2 hospitals nearby for treatment by a hand surgeon.

Interview of Staff A on 2/20/17 at 2:15pm revealed that she recalls SP#11 was evaluated by both the NP and Physician B. She further stated that pt. came with cellulitis of the right hand and leg, and has history of skin popping and describes drug users unable to find veins will inject the drug under the skin. She recalls that both the NP and Physician B was at the bedside. Physician B saw the pt. and discussed with the pt. the transfer to which the pt. agreed for the transfer. She recalls that Physician B said that the pt. needs a hand specialist. She further described the transfer process and recalls giving report to the nurse at the receiving facility. Staff A described her responsibilities on assessments, monitoring, and making sure orders and treatments are given as ordered.


The hospital failed to provide medical treatment within its capacity that minimized the risks for Patient #1 and Patient #11's health.