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Based on review of the facility's Medical Staff By-Laws, review of facility policies, review of medical records, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and stabilizing treatment for 1 patient (Patient #3) with a fractured femur of 32 patients reviewed. The facility failed to contact Patient #3 of diagnostic findings to provide additional stabilizing treatment of an Emergency Medical Condition (EMC) resulting in the patient traveling 29.8 miles to another hospital.

Refer to A-2407

Based on review of the facility's Medical Staff By-Laws, review of facility policies, review of Specialist On-Call Schedules, review of medical records, and interviews the facility failed to provide Stabilizing Treatment within the capabilities of the hospital for one (Patient #3) patient of 32 patients reviewed. The facility failed to notify Patient #3 of diagnostic findings of the Emergency Medical Condition (EMC) to provide additional stabilizing treatment resulting in the patient traveling 29.8 miles to another hospital.

The findings included:

Review of the Medical Staff By-Laws, dated 3/2018, showed "...coordination of care, treatment and services with other practitioners and hospital personnel, as relevant to the care of an individual patient..."

Review of facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 2/5/2021, revealed "...to stabilize means, to provide such medical treatment necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely...MSE [Medical Screening Exam] is not an isolated event but it is an on-going process...the medical record must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized..."

Review of the Specialist On-Call Schedules, dated 2/2023, showed Orthopedics with physicians assigned for daily on-call services. A Radiology group was contracted by the facility to provide after hour (ending between 11:00 PM and 11:30 PM) services for diagnostic imaging interpretation.

Review of the medical record from Hospital A, showed Patient #3 presented to the Emergency Department (ED) on 2/4/2023 at 8:59 PM for the complaint of a fall with a right leg injury. She stated she had fallen on her porch and had severe pain to her right leg and groin area. The pain was described as radiating, sharp, constant and rated as a 10 (on a scale of 1 to 10 with 10 being the most severe pain) and held her knee and hip in flexion (bent toward the body). Her medical diagnoses included chronic health problems of Chronic Regional Pain Syndrome of her Left Arm, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type 2, Chronic Back Pain with Surgery, and Rod Placement in her Right Tibia.

Review of the Emergency Documentation, ED Documents Physician, dated 2/4/2023 at 9:11 PM, showed Patient #3 received a MSE "...help nursing place her in the bed. She cannot get up on her own...holding her thigh underneath her leg close to the knee with complaint of pain to the lower femur area. She is crying and quite distraught in pain..." Further review showed "...Lower extremities-she has tenderness over the quadriceps and hamstrings of the entire right thigh...muscle wasting of the right calf and a scar consistent with prior rod placement...no sensory deficits...no swelling...pain to the right lateral hip...but can move the hip...no external rotation...left lower extremity is without any abnormalities...full range of motion..." At 11:52 PM, the ED Physician documented "...no fractures or dislocations noted on these x-rays...pelvis and right hip did not show any evidence of fracture...no dislocation..." Patient #3's differential diagnoses were Fracture of the Femur, Fracture of the Right Hip, Contusion or Strain of Right Hip.

Review of the Physician's Emergency Documentation, dated 2/5/2023 at 12:33 AM, showed Patient #3 resting comfortably after the administration of Morphine. The physician informed Patient #3 her leg was not fractured. The physician supplied the patient with crutches and to bear weight as tolerated. The physician included in the discharge instructions to follow-up and call for an appointment with her orthopedic physician on Monday, 2/6/2023. Additional discharge instructions included How to Use Cold Therapy, prescriptions, and to return to the ED if symptoms worsened. Her condition was documented as improved and stable. Patient #3 was discharged from Facility A with the diagnoses of Muscle Strain of Right Thigh.

Review of the Diagnostic Radiology exam, dated 2/5/2023 at 6:59 AM, from Radiologist #1 of the x-ray of the Right Hip with Pelvis showed the external rotation view included a linear lucency along the upper and midportion of the intertrochanteric region of the right femur "...findings suspicious for hairline type intertrochanteric fracture of the right femur...if needed, correlation with computed tomography [CT] of the right hip could be obtained..." The x-rays of the anterior posterior and lateral right femur including the bilateral knee and hip joints showed no fractures or dislocations.

Review of Patient #3's medical record from Hospital B's ED on 2/5/2023 at 10:35 AM, showed Patient #3 arrived at the second hospital with complaints of increased low back pain and right groin pain, rated as a '10'. She stated she was unable to ambulate since returning home from Hospital A. Hospital B obtained diagnostic tests including a CT Trauma Scan of the Trunk (Thorax, Abdomen, Pelvis). Results of the CT Trauma Scan, dated 2/5/2023 at 10:19 AM, showed Acute Nondisplaced Fracture of the Right Proximal Femur. An ED Physician Note, dated 11:05 AM, showed "...source of right side pain is a proximal femur fracture..." Patient #3 was admitted to Hospital B with a diagnosis of Acute Nondisplaced Fracture of the Right Proximal Femoral Diaphysis (fracture of the shaft or central part of the long bone) and had surgical Intramedullary Nailing repair of the Right Hip on 2/6/2023.

During a telephone interview on 3/7/2023 at 8:40 AM, Facility A's ED Physician stated Patient #3 held her right thigh in a flexion position and reported pain. She stated she helped the patient onto the ED gurney. She confirmed at night the ED physicians read the x-ray images and then the x-rays were reviewed by the Radiologist the next morning. She stated she was not aware the Radiologist had diagnosed Patient #3 with a hairline fracture until 3/6/2023. She confirmed she read the x-ray as negative. She stated Patient #3 did not meet criteria for hospital admission and she had instructed the patient to follow-up with her orthopedic physician and included those instructions in the discharge instructions. The physician confirmed she ordered x-rays of the right hip and femur and diagnosed Patient #3 with Muscle Strain of the Right Thigh with follow-up to her personal care physician and an orthopedic specialist. She stated she never expected Patient #3 to be pain-free "...debility...chronic back pain...never expected her to be pain-free..."

During an interview conducted on 3/7/2023 at 9:20 AM, Triage Registered Nurse (RN) #1, stated he assisted Patient #3, along with her family, out of her personal vehicle. He stated he recalled she complained of severe pain to her right leg and right hip.

During a telephone interview on 3/7/2023 at 10:52 AM, X-Ray Tech #1 stated Patient #3 was her last patient during her shift. X-Ray Tech #1 stated when she took Patient #3 to Radiology, another Radiology Technician assisted her to transfer Patient #3 on the exam table "...she complained of pain and was adamant she was not going to move..."

During a telephone interview on 3/7/2023 at 12:20 PM, Patient #3 stated she fell on her front porch landing on her right leg and buttocks. She had a history of back surgery and a rod placement in her right tibia. Her family helped her into a personal vehicle. Hospital staff had to assist her from the vehicle into a wheelchair. She stated she was unable to walk on the leg and was screaming in pain. She stated Hospital A's ED physician informed her she had a strained hip and was given crutches. She stated after discharge, she was unable to ambulate and had continued pain. Her family drove her to Facility B. Facility B's ED diagnosed her with a right fractured hip. She was admitted to the facility and the right hip was surgically repaired the following day.

During an interview with the Quality and Risk Manager on 3/7/2023 at 10:30 AM, he stated the facility had the capability to perform a CT of the pelvis and confirmed it was not ordered for Patient #3. He confirmed the facility had not notified Patient #3 of the right hip fracture after the Radiologist diagnosed the hairline fracture.