HospitalInspections.org

Based on review of facility policy, medical record review, observation
and interview, the facility failed to provide stabilizing treatment for one patient (Patient #11) who presented to the Emergency Department (ED) of 20 ED patients reviewed.

The findings include:

Patient #11 presented to the ED on 7/18/2023 at 7:50 PM with "...sudden onset of tearing sensation..." in the right calf. The pain was in the patient's right posterior (back) of the lower leg with a reported pain level of 7 of 10, with 10 being the worst possible pain. The patient's right leg was swollen and tender. Patient #11 received a medical screening exam by a physician at 9:29 PM. The pain increased with dorsiflexion (flex foot upward) of the left [aspect of right] ankle. Patient #11 reported moderate right lower leg pain with limited ability to bear weight. Physical exam showed no knee swelling was present and joint range of motion was normal. Tests for anterior cruciate ligament (ACL) tear and meniscus (knee cartilage) tear were negative. The patient's right posterior leg had bruising and moderate tenderness. Additional findings included "...Tender lower aspect of right calf muscle but none over the Achilles tendon [connects calf muscle to heel] and she is able to dorsiflex the ankle although it hurts in the calf muscle. Neurovascular status is normal..." Diagnostic considerations included "...muscle or tendon injury right calf but Achilles tendon appears to be intact...Patient with acute [sudden onset] muscle strain of right lower calf and likely she has more than just a strain but she possibly has is muscle tear..." An Ace (elastic) bandage wrap was applied to Patient #11's ankle. The patient was instructed to not walk on the right foot for 5-6 days and was encouraged to use crutches until she was able to bear weight. Patient #11 was discharged to home with diagnosis of Muscle Strain Right Calf Muscle. The facility failed to provide specific follow-up instructions with an orthopedic provider. The facility instructed Patient #11 to remain non-weight bearing for 5-6 days, but did not provide a prescription for crutches and they had none in stock for the patient to use as she was non-weight bearing.

Please refer to A-2407.

Based on review of facility policy, medical record review, observation and interviews, the facility failed to provide instructions for adequate follow-up care, failed to provide a prescription for crutches, and failed to provide pain management for one patient (Patient #11) who presented to the Emergency Department (ED) of 20 patients reviewed.

The findings include:

Review of the facility's policy "EMTALA (Emergency Medical Treatment and Labor Act)" revised 8/2022, showed "...Emergency Medical Condition...A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in...serious impairment to bodily functions...serious dysfunction of any bodily organ or part...TRANSFER...The movement (including the discharge) of an individual outside a hospitals facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital...STABILIZATION...When a patient is deemed to have an emergency medical condition, the facility will provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility..."

Medical record review of a nursing note showed Patient #11 presented to the ED via wheelchair on 7/18/2023 at 7:50 PM. The patient was triaged (assessed by a nurse) at 7:52 PM with an Emergency Severity Index (ESI) score (5 level system to determine the risk of patients) of 3, indicating urgent but not emergent needs. The patient reported "...Sudden onset of tearing sensation in right calf..." when she took a step after cleaning water on the floor. The patient's assessment showed the patient's pain was in the right posterior (back) lower leg with a reported pain level of 7 out of 10, with 10 being the worst possible pain. The patient's right leg had swelling and tenderness.

Medical record review of an ED physician note, dated 7/18/2023 at 9:29 PM, showed Patient #11 reported approximately 90 minutes prior to arrival she almost fell, caught herself, and felt pain in the calf muscle. The pain increased with dorsiflexion (flex foot upward) of the "...left [aspect of right] ankle..." She reported moderate right lower leg pain with limited ability to bear weight. The physical exam showed no knee swelling was present and joint range of motion was normal. Tests for anterior cruciate ligament (ACL) tear and meniscus (knee cartilage) tear were negative. The patient's right posterior leg had bruising and moderate tenderness. Additional findings included "...Tender lower aspect of right calf muscle but none over the Achilles tendon [connects calf muscle to heel] and she is able to dorsiflex the ankle although it hurts in the calf muscle. Neurovascular status is normal..." Diagnostic considerations included "...muscle or tendon injury right calf but Achilles tendon appears to be intact...Patient with acute [sudden onset] muscle strain of right lower calf and likely she has more than just a strain but she possibly has a muscle tear..." Patient #11 was discharged to home with diagnosis of Muscle Strain Right Calf Muscle.

Medical record review of physician orders, dated 7/18/2023 at 9:31 PM, showed "...Ace [elastic] wrap 4 inch...Ice to injury...ace wrap is to the ankle to calf with the toes pointing down > [greater than] 90 degrees..."

Medical record review of Patient #11's discharge instructions the facility instructed the patient to remain non-weight bearing on the right foot for 5-6 days. Patient #11 was encouraged to use crutches until she was able to bear weight.

Medical record review of a nursing note, dated 7/18/2023 at 10:05 PM,
showed Patient #11 refused to sign and accept discharge paperwork. "...Angry because we did not have a crutch..."

Medical record review showed Patient #11 did not receive medication for pain while in the ED; there were no specific instructions for follow-up with an orthopedic physician or primary care physician; and there was no documentation to indicate a prescription for crutches was provided for Patient #11.

During an interview on 8/28/2023 at 4:10 PM, in the Chief Nursing Officer's (CNO) office, the ED Nurse Manager confirmed the facility did not have crutches. She stated if crutches were required, a prescription for crutches was given to the patient. The ED Nurse Manager reviewed Patient #11's medical record and stated "...I don't see a prescription for one [crutches]..."

Patient #11 was contacted on 8/28/2023 at 5:35 PM. Patient #11 stated the physician told her this kind of injury would take a while to heal "...but we have no crutches..." She reported she was unable to walk on her leg for about 2 weeks, then was able to put a little bit of weight on it. The patient reported the facility did not have crutches or a boot.

Observation of the ED on 8/29/2023 from 11:30 AM-12:00 PM showed there were no crutches or walking boots in the supply room.