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Based on reviews of medical records, policies and procedures, on-call schedules and interviews the facility failed to contact and or utilize the on-call orthopedic surgeon that was available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services in accordance with the resources available to the hospital for 1 Patient (#1) of 20 sampled patients who sustained a left thumb laceration with a flexor tendon injury. Refer to findings in Tag A-2404.



Based on reviews of medical records, policies and procedure the facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital to provide further evaluation and treatment for one (Patient #1) of 20 sampled closed record reviews. Refer to findings in Tag A-2407.

Based on reviews of medical records, policies and procedures, on-call schedules and interviews the facility failed to contact and or utilize the on-call orthopedic surgeon that was available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions who are receiving services in accordance with the resources available to the hospital for 1 Patient (#1) of 20 sampled patients who sustained a left thumb laceration with a flexor tendon injury.
The findings were:
I. Policies and Procedures
Review of the facility ' s policy and procedure titled, " EMTALA -Medical Screening, Treatment and Related Issues " Last Review Date: 01/13/2012 specified in part, " Statement: This policy sets forth procedures to ensure that the meets all the requirements set forth in the Emergency Medical Treatment and Labor Act ( " EMTALA " ) 42 U.S.C. 1395, for the examination and treatment of patients whom a request for emergency care is made. Any individual who comes to the Emergency department . . . The Hospital will provide treatment to stabilize the condition ... Procedure: Emergency Department ...On-Call Roster . . . 2. Emergency Department personnel shall maintain an on-call schedule of physicians available to continue the MSE (Medical Screening Examination) if needed and to provide stabilizing care in the emergency department. "
The medical record for patient #1 was reviewed. Patient #1 was triaged by a qualified ED nurse at 8:31 p.m., and assigned a triage level 2 (Emergent). Review of the ED (emergency department) Physician Report dated 12/10/14 revealed that patient #1 received a medical screening examination by a Nurse Practitioner (NP#5). The patient ' s Chief Complaint was listed as " Lac, (Lacerated) finger. " Further review indicated in part, " History and Present Illness ... the onset was 1 hours ago ...incident occurred at home ...Location: Left Thumb. The character of symptoms is pain and bleeding ...Additional history: patient describes accidentally cutting his left thumb while trying to cut an apple... Past Medical History/Social History. . . Social History ...he is here visiting a friend in Atlanta and will be staying in the Atlanta area for the next week. Physician Examination: Musculoskeletal: Fingers. . . Left, first proximal to PIP joint (2.5 cm (unit of measure) tendon (a tendon is a thick cord that joins the muscle to bone and causes joint to bend and straighten) involvement, range of motion limited, there is a distal located away from the center of the body) deficit (a functional abnormality of a body area due to a decrease in the function of the muscle) consistent with a tendon injury. . . Procedure: Laceration repair. . 21:00 (9:00 P.M.) . . . Description/ repair: . . . Depth: partial tendon ...Neurovascular /tendon exam: tendon function deficit. . . Skin Closure: #3 sutures, with 4-0 nylon ... The patient was then placed in a thumb spica for thumb support. . . Impression and Plan: Diagnosis: thumb laceration with flexor (a muscle that serves to flex or bend) tendon injury. . . Impression and Plan: Diagnosis: Thumb laceration with flexor tendon injury. . . Plan. . . Disposition: Discharged: to home. . . Follow up with: (named) Orthopedic physician . . . within 5 to 7 days. " The x-ray report dated 12/10/2014 at 8:14 p.m. revealed no acute fracture of the left hand. Care and treatment provided for patient #1 by NP#5 was attested to by ER Medical Director.
Review of the ED on-call physician schedule for December 2014, revealed that there was an on-call orthopedic surgeon an available and capable of performing surgery to the flexor tendon injury. However, the on-call physician was not contacted for consultation. . " The facility failed to utilize and/or contact the orthopedic surgeon that was on call on 12/10/2014 to provide further treatment that was necessary after the initial examination to stabilize patient #1 ' s EMC in accordance with services that were available at the hospital. Patient #1 did not receive definitive surgical treatment until 13 days after the injury.
A review of the medical record revealed that patient #1 presented to Emory University Hospital again on 12/12/2014 at 1:37 p.m. Review of the Emergency Notes and Summary dated 12/12/2014 revealed, " PT (patient #1) registered but could not be found for triage ... Visit Reason: INJ (injury)- L(left) THUMB.
The medical record for Patient #1 from the acute care hospital in Tennessee was reviewed. The medical record revealed that patient #1 presented to the ED at the acute care hospital in Tennessee on 12/23/2015(13 days past the injury) with Chief complaint of " thumb injury. " The History of present Injury, specified in part, " 27 year old presents to the emergency department today complaining of a left thumb injury that happened on December 10, 2014. The patient was in Atlanta working ...accidentally cut the flexor portion of his proximal thumb. He was apparently seen at an outside hospital (Emory University Hospital) where he was seen in the emergency department . . . the skin laceration was sewn and the patient (patient#1) was discharged home. Patient states he was diagnosed with a tendon laceration but states that the tendon was not repaired. . . He does report some tingling in his left thumb. He states that he cannot flex the distal portion of his thumb ...he is a musician. He plays guitar in the base. . . Physical Exam: . . . MUSCULOSKELETAL:. . .L. . . no definite flexor action present at the DIP of the first digit. . . Medical Decision Making/ED course: He was evaluated by hand surgery. He will likely need a tendon graft. It is that several days since this injury occurred . . . He is going to follow-up in hand clinic. The operative report dated 1/6/2015 revealed the patient pre/post-operative diagnosis were Left thumb flexor pollicis longus (FPL) tendon injury ... Findings: " Complete laceration of the FPL tendon was noted.
INTERVIEWS
An interview was conducted with the ED Medical Director on 1/7/2015 at 6:00 p.m. The ED Medical Director stated that he recalled the patient (Patient #1). He continued to state that the lacerated tendons typically need to be repaired by a surgeon, and this one did. He stated that patients were usually referred to see the orthopedic surgeon within 1-2 weeks (which is standard), lacerated tendons are never repaired emergently. They are usually repaired in an out-patient setting. He also stated that it was his belief that waiting for the surgery did not impact the function of the tendon in the hand. He stated that patient #1 was referred to a hand orthopedic and the Nurse Practitioner spoke to the patient about the repair and follow-up

An interview was conducted on 2/24/15 via phone at 12:20 p.m. in the conference room with the Patient Advocate. The patient was seen at the facility on the first visit and discharged with a referral to see an outpatient Ortho for further care or return to the facility if having complications. The patient went to see the Ortho- physician (Out-patient) the first time and had concerns that he was unable to afford the cost if the patient needed surgery. The patient ' s (patient #1) mother felt the patient could return to the facility and have the surgery completed thru the ED and have the on call Ortho-physician come and complete the surgery if needed. The patient returned to the ED the second time and the advocate stated he/she was on a conference call with the parent who explained her idea of what should happen for the patient. The advocate stated the patient returned to the ED by request of his mother to be seen for surgical intervention for the patient ' s finger. The patient was given the opportunity to stay and be seen but decided to leave after clarification was made concerning the patient ' s appointment with the Ortho -physician the patient was originally scheduled to see. There was no documentation in the medical record to indicate that patient #1 was informed to stay at the hospital to be evaluated on his second visit to the ED on 12/12/2014. The Patient Advocate stated that patient#1 also verbalized that he needed to go home (Tennessee) and was told by the Ortho physician at the second appointment that he could also be seen near his home if he did not want to stay in Georgia for continued care.

Based on reviews of medical records, policies and procedure the facility failed to provide stabilizing treatment that was within the capabilities of the staff and facilities available at the hospital to provide further evaluation and treatment for one (Patient #1) of 20 sampled closed record reviews.

Findings include:
The facility ' s policy titled, EMTALA-Medical Screening, Treatment and Related Issues, Last Review Date: 01/13/2012 was reviewed. The policy revealed in part, Scope/Procedure:
Definitions: ... 4. " Stabilized " means that a patient with an Emergency Medical Condition has received appropriate treatment such that no deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the ...discharge of the patient ...Stabilizing Treatment: 1. Any patient who is determined to have an Emergency Medical Condition will be provided further medical examination and treatment as necessary to stabilize the emergency medical condition. "

Review of the Emergency Department (ED) Physician Report dated 12/10/2014 revealed patient #1 presented to the ED with a finger laceration, and tendon injury. The patient reported that while cutting an apple the laceration occurred. The ED physician closed (sutured) the laceration, splinted the thumb and referred the patient to an orthopedic physician for out- patient follow-up in five (5) to seven (7) days.
Review of the ED on-call physician ' s schedules for December 2014, revealed that there was an on-call orthopedic surgeon available when patient #1 arrived to the ED on 12/10/2014 with a laceration flexor tendon injury. The ED physician closed the skin wound and left the tendon injury untreated. On 12/10/2014 Emory University Hospital had staff capability (orthopedic surgeon on call) and facilities to provide further evaluation and/or treatment of patient #1 ' s left thumb flexor tendon injury.
The hospital failed to provide stabilizing treatment that was within the capability of the hospital and facility (equipment) for further evaluation and/ or treatment by the on-call orthopedic physician that was necessary to stabilize the EMC (the flexor tendon injury) for patient #1 on 12/10/2014.