HospitalInspections.org

Based on medical record reivew, facility policy review, and interview, the facility failed to ensure patients who are transferred to another facility have been seen by qualified on-call physicians and received stablizing treatment before being transferred to another hospital for one (#3) of thirty patients reviewed:

The findings included:

Please refer to A-2404

Please refer to A-2409

Based on medical record review and interview, the facility failed to consult the on-call Orthopedic surgeon for the facility before transferring the patient to another facility.

The findings included:

Medical record review revealed patient #3 presented to the Emergency Department (ED) of hospital #1 on May 17, 2012, at 11:07 p.m. with complaints of having jumped twenty feet from a retaining wall to concrete. Continued medical record review revealed the patient complained of pain to the right shin at a level of 10 on a scale of 1-10 with 10 being the worst possible pain.

Review of the Physician On-call Schedule for May 17, 2012, revealed there was an Orthopedic surgeon on call. Review of the ED record revealed no documentation the Orthopedic surgeon was consulted about the patient.

Telephone interview with the Physician Assistant (PA) on June 12, 2012, at noon in the conference room, revealed the patient was already considered a trauma case. Continued interview revealed the PA would have called the Orthopedic Surgeon on call at hospital #1 if hospital #2 had not agreed to accept the patient. Continued interview revealed it depends upon the case as to whether Orthopedics would be consulted but the PA considered a jump of twenty feet to be a trauma. Further interview revealed hospital #2 accepted the patient immediately so the patient was prepared for transfer and splints were not applied to the lower extremities.

Telephone interview with the Medical Director of the ED on June 12, 2012, at 12:10 p.m., revealed the Medical Director had polled ED physician, PA, and Nurse Practitioner staff and 70% said they would have transferred the patient without calling the on-call Orthopedic Surgeon. Continued interview revealed the Medical Director "...would probably have called the Orthopedic Surgeon on-call to let them know the type of injury and plans to transfer the patient...". Further interview with the Medical Director revealed the patient met orthopedic trauma criteria. Continued interview with the Mdeical Director revealed the physician must consider the mechanism of injury and the physicians felt regardless of having orthopedics facilities at hospital #1, the patient needed a trauma center.

Telephone interview with physician #2 on June 14, 2012, at 1:30 p.m., revealed orthopedicas at hospital #1 was not consulted because of the mechanism of injury with the patient falling from twenty feet. Continued interview revealed the physician felt the patient should be evaluated by a trauma surgeon in case there were other injuries. Further interview revealed splints were not applied because the fractures were not unstable and there would have been no threat to the limbs if splints were not applied.

Based on medical record review, facility policy review, and interview the facility failed to ensure a patient with multiple orthopedic injuries was adequately stabilized with intravenous access and splints for orthopedic injuries before transfer to another facility for one (#3) of thirty patients reviewed.

The findings included:

Medical record review revealed patient #3 presented to the Emergency Department (ED) on May 17, 2012, at 11:07 p.m., with complaints of having jumped twenty feet from a retaining wall to concrete. Continued medical record review revealed the patient complained of pain to the right shin at a level of 10 on a scale of 1-10 with 10 being the worst possible pain.

Medical record review revealed the Physician Assistant assessed the patient at 11:31 p.m. and found the patient to have "...left ankle with periauricular swelling and tender to palpation; extension and flexor intact. Range of Movement in ankle limited in ankles bilaterally due to pain. Right ankle with swelling and tender to touch and palpation; extensors and flexors intact. Distal pulses equal and present x4...".

Medical record review revealed the patient was assessed at 11:16 p.m., by the Triage Nurse who documented "...pt. (patient) jumped off a ledge onto concrete from 15-20 feet up. Both ankles are swollen and scratched up. Pt. Also complains of pain to right shin...".

Medical record review revealed the patient was assessed by nursing at 11:20 p.m. and stated pain was at a level 10 on a scale of 1-10 with 10 being the worst pain.

Medical record review revealed the patient had an IV (intravenous line into vein to administer fluids) started at 12:24 a.m., in the left antecubital area. Continued review revealed the patient received Dilaudid (pain relief) 0.5 mg (milligrams) IV and Zofran (anti-nausea) 4 mg at 12:30 a.m., and another dose of Dilaudid 0.5 mg IV at 12:55 a.m.

Medical record review of a medical note written by the Physician Assistant on May 17, 2012, and untimed, revealed "...Discussed and review all x-rays with (named physician #2). We discussed further imaging versus transfer. Agreed to transfer. Spine is non-tender to touch and palpation. (named physician) at hospital #2 accepts transfer of patient per transfer center at 12:46 a.m...".

Review of the transfer form dated May 17, 2012 revealed the reason for transfer was "...health care services required are not available at (named hospital #1). The patient has been stabilized within reasonable medical care standards. No further deterioration is likely as a result of the transfer...".

Medical record review revealed the patient was transported to hospital #2 on May 18, 2012, at 1:35 a.m., per ambulance.

Review of the Emergency Record from hospital #2 dated May 18, 2012, at 1:45 a.m., revealed the statement by the ED physician "...Called (named hospital #1) and spoke with (named physician #2). Told him stable VS (vital signs) and that IV had been removed before transport...".

Review of hospital #1s ED policy entitled Standard of Care - Orthopedic Emergencies (Extremities) ECC - 01025, revealed "...The treatment and management of the patient with an orthopedic emergency to any extremity may include the following: 8. Obtain IV..."

Medical record review of a nursing note dated May 18, 2012, at 1:59 a.m., revealed an IV was started in the patient's left hand at hospital #2.

Telephone interview with the Physician Assistant (PA) on June 12, 2012, at noon, in the conference room, revealed the patient was already considered a trauma case. Further interview revealed an IV is usually in place when a patient is transferred to another facility. Continued interview revealed "...I believe it is protocol for patients to have IV access with transfer...".

Telephone interview with the Medical Director of the ED on June 12, 2012, at 12:10 p.m., revealed most patients have an IV in place when transferred. Continued interview with the Medical Director revealed "...Any patient who goes by ambulance from one facility to another should have an IV...".

During interview on June 12, 2012, at 1:30 p.m., in the conference room, the ED Director confirmed the patient did not have IV access present on transfer and all transfer patients are required to have IV access.

Telephone interview with physician #2 on June 14, 2012, at 1:30 p.m. revealed splints were not applied because the fractures were not unstable and there would have been no threat to the limbs if splints were not applied.

Continued telephone interview with physician #2 on June 14, 2012, at 1:30 p.m., revealed patients are usually transferred with IV access in place. Continued interview revealed physician #2 was unaware there was no IV access during the transfer and stated "...I would have wanted one..."