HospitalInspections.org

Based on findings at A2407, the facility failed to ensure complaince with CFR 489.24.

Based on interview and record review, the facility failed to provide continuation of treatment to stabilize an emergency medical condition for 1 of 43 sampled patients (Patient #21).

Findings include:

Patient #21 presented to the hospital emergency department on 8/4/10 at 1:30 AM, with a chief complaint of a right hip fracture. The patient was transferred to the hospital emergency department from another hospital due to the transferring hospital did not provide pediatric services.

Patient #21 was triaged on 8/4/10 at 1:30 AM. The patient was running and fell on the right hip. The patient's pain level was a 4 out of 10 on a numeric pain scale.

The patient was transferred to a room and a nursing assessment was initiated on 8/4/10 at 1:40 AM. The nursing assessment indicated the patient was in no acute distress, alert, and active. The patient was not in respiratory distress with normal breath sounds, regular heartrate, pulses were equal and strong and capillary refill was less than 2 seconds. The patient was alert and oriented times three, pupils were equal and reactive to light, patient maintains eye contact, no evidence of trauma to head and abdomen. The pelvis inspection was normal, abdomen soft and non-tender and the bowel sounds were normal. The extremities exam revealed the patient was guarded to the right hip.

The Emergency Department Physician record dated 8/4/10 documented the chief complaint was a right hip injury which started two days ago. The patient had fallen and landed on the right hip. The physical exam revealed the patient was in no acute distress. The extremities inspection of the foot/ankle showed normal inspection, non-tender, normal skin color/temperature, skin was intact, normal toe exam and normal range of motion. The leg inspection was normal, non-tender and no evidence of ischemia. The knee inspection was normal, non-tender, no joint swelling and normal range of motion. The thigh/hip inspection revealed tenderness, limited range of motion and hip pain on leg movement. The pelvis was stable and gait was limited by pain. The physician indicated the computerized tomography (CT) scan showed the right femoral growth plate was widened. The initial fracture care was provided greater than 24 hours. The case was discussed with pediatric orthopedic physician (Physician #2). The clinical impression was a right slipped capital femoral epiphysis. The patient was discharged home in good and stable condition.

The CT scan of the pelvis without contrast (done at the transferring hospital on 8/3/10 at 11:35 PM) revealed the following: "Hip joints are preserved and symmetrical, however, the right femoral growth plate is wider than the left and there appears to be mild angulation between the femoral head and neck. No fracture is identified. Small right joint effusion is noted. No other soft tissue abnormality is seen...impression: Findings may be worrisome for injury to the growth plate of the right femur as discussed above..."

The hip joint x-ray (done at the transferring hospital on 8/3/10 at 7:27 PM) revealed the following: "There is a chronic-appearing deformity of the right femoral neck which appears slightly curved in contour. However, there is also widening and slight irregularity of the femoral capital epiphysis which may represent a superimposed acute physeal injury. The acetabulum shows grossly normal contour and appears bilaterally symmetric. Comparison views of the left femoral neck and femoral capital epiphysis are unremarkable...Pediatric orthopedic consultation is advised..."

Patient #21 was medicated with Lortab 5 milligrams by mouth on 8/4/10 at 2:20 AM.

Patient #21 was given crutches on 8/4/10 at 2:10 AM and instructed on the use of the crutches. The patient demonstrated appropriate use of the crutches. The patient was discharged home with parents on 8/4/10 at 2:20 AM in stable and improved condition. The patient was given the following discharge instructions: a prescription for Lortab 5/500 milligram tablets to take one tablet every 8 hours as needed; follow-up with orthopedic physician (Physician #2) name, address and telephone number was provided.

On 9/10/10 at 11:20 AM, Physician #1 revealed the patient was transferred to the hospital emergency department due to the transferring hospital did not provide pediatric services. Physician #1 revealed the slipped capital epiphysis was a congential or a traumatic fracture which was specific to pediatrics. Physician #1 consulted with Physician #2 on the telephone, discussing the results of the CT scan, hip joint x-ray and the patient's physical exam results. Physician #2 recommended the patient be given crutches with instructions to keep off the leg (non-weight bearing), be given pain medication, and to see Physician #2 within 48 hours. Physician #1 indicated the slipped capital epiphysis fracture did require surgery to pin the fracture back into place. Physician #1 indicated the patient's slipped capital epiphysis fracture was a stable fracture and the repair could be done by elective surgery. Physician #1 indicated the fracture did not require immediate emergency surgery for repair.

On 9/13/10 at 2:00 PM, Physician #2 indicated that based on the hip joint x-ray results, the CT scan results and the emergency department physician physical exam results, the patient had a mild and stable slipped capital epiphysis fracture. Physician #2 indicated the standard treatment for a mild stable slipped capital epiphysis fracture was to place the patient on crutches and to have the patient come to the office for consultation and to schedule surgery. Physician #2 indicated a mild and stable slipped capital epiphysis was not an emergency medical condition which would require admission and immediate surgery. Physician #2 indicated that based on the findings, it would appear the slipped capital epiphysis fracture was about 3-4 months old.

The patient presented to another area hospital emergency department on 8/5/10. The emergency department record indicated the patient was running while she was playing yesterday, tripped and fell on her right leg. The patient's mother indicated the patient had always walked kind of funny. The patient was evaluated at another area hospital and was discharged to outpatient management. The patient's mother had contacted Physician #2's office to schedule an appointment and was informed the office visit would cost $500.00. The patient's mother stated she did not have the funds to pay for the office visit. The patient's mother went to the Medicaid office for assistance and was informed to go to the emergency department for services. The emergency department physician consulted with a pediatric orthopedic physician (Physician #3) and discussed the case. Physician #3 indicated he would care for the patient and will take the patient to the operating room this evening.

A review of the findings by a quality improvement organization physician revealed the facility had the capability of providing the necessary treatment to care and stabilize the patient's emergency medical condition of the slipped capital femoral epiphysis fracture.