HospitalInspections.org

Based on review of medical records, ambulance run sheet, and staff interviews the facility failed to ensure that an appropriate transfer was provided to another acute care hospital for an individual who was discharged from the hospital with an identified emergency medical condition for 1 (#1) of 20 sampled patients. Refer to findings in Tag A-2409.

Based on a review of medical records, ambulance run sheet, and staff interviews the facility failed to ensure that an appropriate transfer was provided to another acute care hospital for an individual who was discharged from the hospital with an identified emergency medical condition for 1 (#1) of 20 sampled patients.

Findings:

1. Ambulance Run Sheet

Review of Patient #1's ambulance run sheet dated 11/29/2016 at 10:05 AM, revealed that Patient #1's chief complaint was a traumatic injury to the upper extremity". Patient #1's BP in the ambulance unit was listed at 10:05 AM as B/P (Blood pressure) 223/120; Pulse -101, strong, regular; Respirations 20 Normal, Regular, and oxygen saturation was 100% on room air. Review of the narrative section revealed in part, "911 call ADVISED (sic advised) PT (Patient) IN ROUTE TO STATION WITH THUMB NEARLY CUTOFF. MET PA OUTSIDE AND ASSISTED TO UNIT. BLEEDING CONTROLLED IN ROUTE TO LEFT THUMB STILL ATTACHED ON LOWER SIDE. V/S (VITAL SIGNS) SHOWED B/P ELEVATED. INT(intravenous access) ATTEMPTED X1 WITH SUCCESS. NO OTHER CHANGES OR TREATMENT DUE TO ARRIVAL AT MIDTOWN MEDICAL CENTER ER (EMERGENCY ROOM) CARE LEFT WITH NURSING STAFF."

2. Medical Record Review Patient #1 - Midtown Medical Center (Hospital A)

Documentation by the Emergency Department Nurse dated 11/29/2016 at 10:55 AM on the Interventions/Assessments/Treatments sheet revealed that Patient #1 was coming in via ambulance for a partial left thumb amputation. Patient #1's chief complaint was "extremity pain/injury." Patient #1 was triaged at 10:55 AM as a Level "3-Urgent." Patient #1's pain to his left hand on a Numeric Pain Scale was listed as "10 - Severe/Worst Possible." Patient #1's vital signs (VS) were: pulse- 111; respiratory rate-22; B/P 233/126. Oxygen saturation was 100% on room air. An intravenous line (a thin plastic [catheter] inserted into the vein to deliver medications and fluids) was started at 11:14 AM on Patient #1's right hand with an 18 (eighteen) gauge needle. Patient #1's VS at 1:00 PM were: pulse - 77; blood pressure - 142/67; respiratory rate - 18. The ED (Emergency Department) physician record dated 11/29/2016 was reviewed. The attending ED physician (Credential #6) documented in part, "Narrative History of Present Illness ... male presents to the ED with acute severe left thumb open fracture that occurred just PTA (prior to admission). Patient reports operating on a ...truck and states injuring his left thumb between the automatic metal rails ...Physical Exam-General Adult ...Extremities upper: abnormal inspection (Open fracture of left thumb. Left distal thumb appears macerated with slight blanching), tenderness (severe diffuse, left thumb) ...Procedures: laceration ...Location of wound: Left thumb, Anesthesia agent: lidocaine, Digital block: yes, wound prep: betadine, normal saline, Debridement: yes ...explored for foreign body ... repair-skin: 4.0 nylon, Number of sutures: 3 ... Re-eval. (Evaluation): re-examined, Re-eval. following treatment: other (Status-post suture management; Left distal thumb still slightly blanched and macerated ...Consultant called: Orthopedic (PA) Requested call at 12:45 PM. Call returned: Call returned at 1:17 PM Consultant: Other (Ortho notified, reports no hand surgery coverage) ... Re-evaluation comment: Patient and family aware that we do not have hand surgeon. They are concerned about 'losing the thumb and will take the patient to a facility with a hand surgeon when patient discharged.' The section of the note titled "Disposition -General Adult Certified Medical Emergency -Yes, Discharge Disposition: Home. The attending ED physician documented "Clinical Impression: Fracture of thumb, left, open ... Condition: Serious ... Prescriptions: Keflex (antibiotic) 500 mg PO (by mouth) Q (every) 6 ... Norco 5-325 tablet (pain medication) 1 each PO Q4 ... Instructions: ED Fx (fracture) Thumb. Additional Instructions: Follow-up with hand surgeon immediately."

The first x-ray dated 11/29/2016 at 11:21 AM was reviewed. The findings revealed in part, "1. Complete fracture of the distal left shaft of the proximal phalanx (bones of the fingers and toes) of thumb noted with significant displacement of the distal fragment ...Conclusion: 1. Fracture of the distal shaft of the proximal phalanx of the thumb with significant displacement. 2. Degenerative changes involving the carpal bones as described. The second x-ray reviewed dated 11/29/2016 at 3:00 PM specified in part, "Conclusion: 1. Interval reduction of the known fracture of the proximal phalanx of the thumb with improvement in the alignment. A splint is noted."

Review of the discharge instructions revealed that Patient #1 received the instructions on 11/29/2016 at 3:04 PM which included the instruction to 'follow-up with hand surgeon immediately.' Further review of the record revealed that Patient #1 physically left the hospital with his/her family at 3:30 PM with discharge instructions.

3. Medical Record review for Patient #1 at Hospital B.

Review of the medical record revealed that Patient #1 arrived at Hospital B on 11/29/2016 at 3:45 PM. Patient #1 was triaged an ESI (Emergency Severity Index - triage based on the acuity of a patient's health care problems and the number of resources their care is anticipated to require) -2 Emergent. The ED physician at Hospital B documented at 4:04 PM that Patient #1 walked into the ED with complaints of "Thumb Injury." The ED physician further documented in part that, "the patient or guardian reports deformity, pain. The complaints affect the palmar aspect of distal phalanx of left thumb and palmar aspect of proximal phalanx of the left thumb. The ED physician's notes further revealed that Patient #1 was seen at 'Hospital A' where they loosely reattached his/her thumb and discharged him/her instructed Patient #1 to come to Hospital B because Hospital A did not have a hand surgeon. The ED physician's examination at 4:15 PM revealed that Patient #1's palmar aspect of distal phalanx of left thumb was severed and that the tip of the thumb was cyanotic (bluish or purplish discoloration of the skin due to insufficient oxygenation of the blood), and decreased sensation was noted. At 4:29 PM the ED physician documented "L (left) distal thumb is dusky and does not appear to have blood supply ...Only very small piece of skin remains connecting the 2 sections." The ED physician also documented that he/she was consulting with the hand surgeon on call. Further documentation revealed that the ED physician had spoken to the hand surgeon, and was informed that he/she (the on call hand surgeon) will call the Operating Room to schedule Patient #1 for surgery and that he/she would evaluate Patient #1 in the pre-op holding area. Patient #1 was admitted to Hospital B. The hand surgeon's consultation report revealed that the left thumb was examined, "The distal component is cyanotic. There is a near circumferential laceration except for a 1 cm or less volar soft tissue flap. He/she has exquisite pain upon palpitation ...approximately 4 nylon sutures loosely placed. There is no skin turgor. Nail bed is completely cyanotic. The tip is cold. There is absolutely no flexion of the interphalangeal joint as well. .. Assessment: Amputation of the left thumb, status post 9 hours ago." Further documentation revealed that Patient #1 was taken emergently to surgery on 11/29/2016.

4. Interviews

During an interview with the charge nurse (RN, Staff #1) on 12/19/2016 at 12:45 PM, he/she revealed that for EMTALA patients must be seen, even though they can't pay, they must be seen. He/she also stated that transfers must be appropriate - higher level of care, and the paperwork must accompany the patient, and a nurse to nurse report should be completed.

A telephone interview was conducted with the ED physician (Credential #6) who cared for Patient #1 on 11/29/2016 at 9:55 AM. The ED physician stated that Patient #1 had a left thumb injury with an open fracture, total displaced, was wrapped on arrival, and that an x-ray confirmed a fracture. He/she also stated that the open fracture was reduced and sutured-primary closure, wrapped and splinted. He/she further stated that the thumb was re-X-rayed and needed orthopedic follow-up. It could have waited until the next day or two, but it would have been preferred that it be seen as soon as possible - within 24 hours would have been good. He/she also stated that it was not a situation that required immediate surgery. The ED physician further explained that the statement "hand surgeon immediately" is a generic statement for this type of injury. There was no name or facility recommended, only to an orthopedist, follow-up. The family seemed determined to go somewhere because they were concerned about the thumb. He/she further stated that the thumb was stable, was not an amputation, just a nasty fracture.

An interview was conducted with the charge nurse of the Adult ER (RN, Staff #3) on 12/19/2016 at 2:05 PM. He/she stated that Patient #1 came in by EMS (Emergency Medical Services), with an on-the-job injury of a laceration/potential amputation. Patient #1's acuity level was ESI-3, and care was provided by a paramedic. Staff #3 recalled asking the physician if Patient #1 needed to be transferred. The physician stated to discharge Patient #1 home and to follow-up with a hand surgeon. Patient #1 was up and walking inside the patient room. Staff #3 also stated that the paramedic did the discharge instructions and that he/she never saw the injury, because Patient #1's injury was not assessed during the triage process. Staff #3 stated that the paramedic provided the primary care for Patient #1.

The paramedic (Staff #2) who provided the primary care for Patient #1 on 11/29/2016 was interviewed on 12/19/16 at 3:00 PM. Staff #2 stated that Patient#1's left thumb injury was bandaged and had some blood loss. Staff #2 further stated that the RN Charge Nurse (Staff #3) was asked about the level of triage; Staff # 3 looked at Patient #1 from approximately 20 feet. The patient's vital signs were stable with bleeding well controlled. Staff # 2 stated that he/she never saw the injury until after the physician had reduced the break. The ED physician did suture the thumb and instructed Patient #1 to follow-up with hand surgeon per discharge instructions.

An interview was conducted with the nurse manager (RN, Staff #1) on 12/21/2016 at 10:15 am. The nurse manager stated that as it relates to EMTALA: "everyone must be seen, no one can be turned away. For transfers, the patients must be stabilized before transfer.

The facility failed to coordinate an appropriate transfer of Patient #1 to another acute care hospital to ensure that appropriate medical treatment was provided for Patient #1's serious left-hand injury; instead, the patient was discharged to home with a certified emergency medical condition and instructed to immediately follow-up with a hand surgeon.