HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to ensure an accurate and complete medical screening examination and failed to provide stabilizing treatment for 1 patient (#24) who presented to the Emergency Department (ED) after suffering a burn of 25 patients reviewed.

The findings include:

Medical record review showed Patient #24 presented to the ED on 4/26/2023 with burns to the right wrist and hand, the right forearm, second degree burn to abdominal wall, and first degree burn to the right breast after a grease fire. The patient was assessed by the ED Physician. While in the ED, the wounds were cleaned with sterile water and dressed with Silvadene cream (ointment to prevent wound infection) and a non-adhesive dressing was applied. There was no documentation regarding the patient's tetanus status and no tetanus booster was given. The patient was informed to contact and follow-up with her primary care provider or the regional burn center (Facility C). There was no documentation related to consult with the regional burn center for the patient's burns.

Medical record review showed on 4/27/2023 Patient #24 presented to Facility B for a second opinion and pain control. A tetanus booster and antibiotics were administered. The regional burn center (Facility C) was consulted and agreed to accept the patient for further treatment.

Medical record review showed on 4/27/2023 Patient #24 presented to Facility C where she was admitted to the step-down burn unit. Review showed on 5/1/2023 the patient required excision and grafting of right hand, forearm, breast, and abdomen. The patient was discharged on 5/6/2023.

Refer to A-2406 and A-2407

Based on review of facility policy, medical record review, and interview, the facility failed to provide a complete and ongoing medical screening examination for one patient (#24) who presented to the Emergency Department (ED) after suffering a burn injury of 25 patients reviewed.

The findings include:

Review of facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines" last reviewed 10/2022, showed "...Medical Screening Examinations [MSE] will be conducted by a Qualified Medical Professional [QMP]...MSE may include any of the following elements; assessments of chief complaint as recorded in the patient's triage record; vital signs upon admission and upon discharge or transfers...focused physical examination of affected and//or potentially affected system...an exam appropriate to the organ system related to the chief complaint...notification and use of on-call physicians to diagnose and/or stabilize the patient's condition...Emergency Medical Condition [EMC]; a medical condition manifesting itself by acute symptoms of sufficient severity...such as the absence of immediate medical attention could reasonably be expected to result in [a] placing the health of an individual...in serious jeopardy...[b] serious impairment to bodily organs...[c] serious dysfunction of any bodily organ or part..."

Medical record review showed Patient #24 was admitted to Facility A on 4/26/2023 with complaints of burns to her hand and body.

Medical record review of an ED Nursing Triage record dated 4/26/2023 at 4:59 PM, showed the patient was moving hot oil off the stove after the pot had caught on fire. The patient stated she had burns to her right hand and part of her stomach. There was unblanchable skin to the right hand with sloughing skin.

Medical record review of an ED Physicians Record dated 4/26/2023 at 6:09 PM, showed the patient had burns to her right hand, forearm, and the right side of her body due to cooking with oil and it caught on fire and splashed onto her body. The burn caused blistering to the dorsal aspect of the right hand and wrist, the pads of her right 3rd and 4th fingers, her forearm, her right lateral and inferior breast, and her right abdomen. The patient complained of severe pain. The physical examination showed "...second degree burns with blistering to the right hand and dorsal wrist and forearm with some denuded skin. Some of these areas are erythematous, some white, sensation is intact, no definite circumferential burns to the fingers, hand or wrist. Large area of redness and early blistering to the right lateral abdomen, approximately 40 cm [centimeters] and right breast..."

Medical record review of an ED Physicians Disposition dated 4/26/2023 at 6:10 PM, showed her diagnoses included burn to the right wrist and hand, burn to right forearm, second degree burn to abdominal wall, and first degree burn to the right breast.

Medical record review of an ED Nurses Note dated 4/26/2023 at 7:01 PM, showed the patient was discharged at 7:10 PM.

Medical record review of an admission History and Physical from Facility C dated 4/28/2023 at 12:03 AM, showed the patient was transferred from Facility B with 3% Total Body Surface Area (TBSA) mixed deep partial and full thickness burn wounds to right chest, right abdomen, and right hand/forearm. She had been seen at (Facility A) after the initial event and had 'some simple wound care' and was discharged home with Silvadene cream. The next morning, she had woken up with severe pain and bleeding to the hand. She was given a tetanus booster, Rocephin 1 gram IM and the wounds were treated [at Facility B].

Medical record review of a Discharge Summary from Facility C dated 5/6/2023 at 11:24 AM, showed the patient was admitted to the Burn Stepdown unit for treatment. On 5/1/2023 the patient was taken to the Operating Room for excision and grafting of R hand, forearm, breast, and abdomen. The patient's wound and graft healed well and she was placed on oral pain medications. The patient was discharged home with follow-up appointments scheduled for 5/12/2023.

During an interview on 3/28/2024 at 1:50 PM, Registered Nurse (RN) #1 stated burns were treated and dressed depending on the physician's orders. The patient's tetanus status would be assessed by the nurse and the physician, and a booster would require a physicians order.

During a telephone interview on 3/28/2024 at 2:25 PM, ED Physician #2 stated the patient's burns were not circumferential. She had second degree burns to the abdominal wall and first and second to the right arm. ED Physician #2 stated "...I did not think the burns would require any skin grafting or any need for transfer. I talked to the patient about the wounds and the plan of care for the wounds. I did discuss with her related to follow up with her primary care provider or with [Facility C]. She was given [Facility's C's] burn center number for follow-up. I normally would document any concerns related to the tetanus status but there was no documentation..."

In summary, the hospital did not consult or transfer the patient to a burn unit for definitive care. In addition, the patient's tetanus immunization was not updated.

Based on review of facility policy, medical record review, and interview, the facility failed to provide stabilizing treatment for one patient (#24) who presented to the Emergency Department (ED) after suffering a burn injury of 25 patients reviewed.

The findings include:

Review of facility policy, "Emergency Medical Treatment and Active Labor Act (EMTALA) Guidelines" last reviewed 10/2022, showed "...stabilizing treatment: if an individual has an emergency medical condition, further medical examination and treatment as is within the hospital's capacity and capability will be administered as required to stabilize the medical condition. The hospital must continue to provide care until the condition ceases to be an emergency or until the individual is properly transferred to another facility..."

Medical record review showed Patient #24 was admitted to Facility A on 4/26/2023 with complaints of burns to her hand and body.

Medical record review of an ED Nursing Triage record dated 4/26/2023 at 4:59 PM, showed the patient was moving hot oil off the stove after the pot had caught on fire. The patient stated she had burns to her right hand and part of her stomach. There was unblanchable skin to the right hand with sloughing skin. The patient was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent needs.

Medical record review of an ED Physicians Record dated 4/26/2023 at 6:09 PM, showed the patient was cooking with oil, it caught on fire and splashed onto her body. The burn caused blistering to the dorsal aspect of the right hand and wrist, the pads of her right 3rd and 4th fingers, her forearm, her right lateral, inferior breast, and right abdomen. The patient complained of severe pain. The physical examination showed "...second degree burns with blistering to the right hand and dorsal wrist and forearm with some denuded skin. Some of these areas are erythematous, some white, sensation is intact, no definite circumferential burns to the fingers, hand or wrist. Large area of redness and early blistering to the right lateral abdomen, approximately 40 cm [centimeters] and right breast..."

Medical record review of an ED Physicians Disposition dated 4/26/2023 at 6:10 PM, showed "...presented with fairly significant burns to her right upper extremity and right chest abdomen...a few of these areas have blistered. Denuded skin was removed with cool water and washed. Silvadene [cream used to prevent infection] dressings applied. Patient will be prescribed Ibuprofen [anti-inflammatory medication] and Hydrocodone [pain medication] for pain control. Recommended Silvadene dressing changes once daily for the next several days. Wound recheck with primary care or at [Facility C] burn center, although do not anticipate any of these will require skin grafting or any significant intervention..." Her diagnoses included burn to the right wrist and hand, burn to right forearm, second degree burn to abdominal wall, and first degree burn to the right breast. There was no documentation of a consult with the regional burn center related to the patient's injuries or the patient's tetanus status.

Medical record review of an ED Nurses Note dated 4/26/2023 at 7:01, PM showed "...burns cleaned with sterile water and dried. Silvadene placed to burns and telfa used to cover. Patient tolerated well..." The patient was discharged at 7:10 PM.

Medical record review of an ED Nursing Triage record from Facility B dated 4/27/2023 at 2:30 PM, showed the patient was heating oil on 4/26/2023 where the oil caught on fire. She picked the pan up and spilled the oil of her right hand and right chest resulting in immediate blistering. She was evaluated at (Facility A) on 4/26/2023 where they "...cut the skin off and cleaned it up and told pt. [patient] to follow-up with her PCP [primary care provider] in two weeks. Last tetanus shot was unknown. Came to ED today for pain and concern that she needs to follow-up sooner than two weeks. There is a large area of open skin on top of the right hand and blister on top of pointer finger, also has open blisters on R [right] chest and small spots on feet and L [left] hand..."

Medical record review of an ED Physicians record from Facility B dated 4/27/2023 at 4:12 PM, showed the patient suffered a burn to the right hand, right breast, and right abdominal wall on 4/26/2023. She had been evaluated at a local ED and discharged home with Silvadene cream. The patient came to the ED for second opinion due to worsening pain and bleeding of the right hand. She was not sure when she had received a tetanus booster. Facility C's burn center was consulted at 3:20 PM and discussed with the transfer center. Picture of the burns were sent and the patient's presentation was discussed with the burn specialist at (Facility C). The recommendation was for transfer for admission to the burn center. The plan of care was discussed with the patient and spouse who were in agreement with the plan. The patient received a tetanus booster and 1 dose of Rocephin (antibiotic) 1 gram intramuscular (IM). The burns were dressed with Bacitracin (antibiotic ointment), Xeroform (dressing) and bulky dressing. The patient was discharged in stable condition for transfer to Facility C.

Medical record review of an admission History and Physical from Facility C dated 4/28/2023 at 12:03 AM, showed the patient had 3% Total Body Surface Area (TBSA) mixed deep partial and full thickness burn wounds to right chest, right abdomen, and right hand/forearm. She had been seen at an outside hospital (OSH) after the initial event and had 'some simple wound care' and was discharged home with Silvadene cream. The next morning, she had woken up with severe pain and bleeding to the hand and went to Facility B for further evaluation. She was given a tetanus booster, Rocephin 1 gram IM and the wounds were treated. She was transferred to Facility C for treatment. The patient was admitted the step-down burn unit.

Medical record review of a Discharge Summary dated 5/6/2023 at 11:24 AM, showed on 5/1/2023 the patient was taken to the Operating Room for excision and grafting of R hand, forearm, breast, and abdomen. The patient's wound and graft healed well. Wound care was discussed with the patient and her parents. The patient was discharged home with follow-up appointments scheduled for 5/12/2023.

During an interview on 3/28/2024 at 1:35 PM, ED Physician #1 stated burn wounds would be assessed during the medical screening examination and the plan of care would be addressed depending on the findings. Transfer would be based on the severity of the assessment findings. Physician #1 stated [Facility C's] burn specialist were very helpful and were very open to consult, review of pictures, and advisement for wound care.

During an interview on 3/28/2024 at 1:50 PM, Registered Nurse (RN) #1 stated burns were treated and dressed depending on the physician's orders. The physician would make the decision for transfer or the disposition of the patient. If a patient was discharged home, the patient would be informed of how to change the dressing. The patient's tetanus status would be assessed by the nurse and the physician, and a booster would require a physician's order.

During a telephone interview on 3/28/2024 at 2:25 PM, ED Physician #2 stated the patient's burns were not circumferential. She had second degree burns to the abdominal wall and first and second to the right arm. The patient was assessed, her pain was treated, and she was monitored for several hours in the ED. The burns did not progress, and the patient was stable from a pain standpoint and related to the burns. The burns did require some debridement and were cleaned with sterile saline. The wounds were dressed with Silvadene cream, a non-adhesive dressing and wrapped with kling. ED Physician #2 stated "...I did not think the burns would require any skin grafting or any need for transfer. I talked to the patient about the wounds and the plan of care for the wounds. I did discuss with her related to follow up with her primary care provider or with [Facility C]. She was given [Facility's C's] burn center number for follow-up. I normally would document any concerns related to the tetanus status but there was no documentation..."

In summary, the hospital did not consult or transfer the patient to a burn unit for definitive care. In addition, the patient's tetanus immunization was not updated.