HospitalInspections.org

Based on policy review, medical record review and interviews the hospital failed to ensure that an adequate medical screening examination and stabilizing treatment was provided for a patient who presented to the hospital's DED for evaluation on 11/16/2018.

The findings include:

1. The hospital failed to ensure that an adequate medical screening examination was provided for a patient (Patient #6) who presented to the hospital's DED for evaluation of bilateral ankle fractures on 11/16/2018.

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

2. The hospital failed to ensure that stabilizing treatment was provided for a patient (Patient #6) who presented to the hospital's DED for evaluation of bilateral ankle fractures on 11/16/2018.

~cross refer to 489.24(d) (1-3), Stabilizing Treatment - Tag A2407.

Based on policy review, medical record review, ambulance report review, manufacturer user guide review, and interviews it was determined the hospital failed to ensure that an adequate medical screening examination was provided for a an individual within the capability of the hospital's emergency department by failing to remove a left leg splint and evaluate the patient's left ankle for 1 (#6) of 26 sampled patients.

Findings included:

Review of hospital policy titled "EMTALA Information - Medical Screening" effective 01/2018, revealed, "...A Qualified Medical Person shall provide a Medical Screening Examination to all patients who come to the Emergency Department ... If an Emergency Medical Condition is detected, Necessary Stabilization Treatment to Stabilize a patient's Emergency Medical Condition shall be rendered in the hospital of an Appropriate Transfer shall be initiated ... Definitions ... Emergency Medical Condition ("EMC") ... A medical condition shown by acute symptoms severe enough that without prompt and appropriate medical attention could result in ... Serious dysfunction of any bodily organ or part ... Medical Screening Examination The initial and on-going evaluation of the presenting patient including ... physical examination ... evaluation of the patient ... Necessary Stabilizing Treatment That medical care necessary to Stabilize an Emergency Medical Condition ... Stabilize With respect to an Emergency Medical Condition, to provide whatever treatment of the condition is necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the Transfer ... of the individual ..."

Review of manufacturer user guide titled "SAM Splint User's Guide" revealed, "...Ankle Stirrup ... If footwear is removed or whenever the ankle is exposed, place padding above and around the boney prominences on each side of the ankle ..."

Review of an Emergency Medical Services (EMS) ambulance call report written on 11/17/2018 at 0622 by Paramedic #1 revealed, "Date: 11/16/2018 ...Flow Chart ...22:27 IV Therapy 22 ga (gauge); Hand-Right ... 22:30 Fentanyl 75 Micrograms ... Intravenous (IV) ... 22:32 Splint Fx (fracture)/Disloc. (Dislocation) Patient Response: Unchanged; Successful ... 22:53 Fentanyl 25 Micrograms ... IV ... Narrative ... The patient was jumping from the trampoline to the inflated air pit. I was told the patient had done a flip and landed cross legged. The patient states that he heard a pop in his ankle and it began to hurt ... There was an obvious deformity noted to the patients (sic) left ankle. The patient had good PMS (Pulse Motor Sensation) noted distal to the injury. The patients (sic) right leg had an abnormal sensation but there was no pain upon palpation and no deformities noted. The patient had good pulse and motor in the right foot ... The patients (sic) ankle was then splinted with the use of a SAM splint. The patient had good PMS in the patients (sic) foot after splinting ... Upon arriving at the hospital the patient was brought to ER room number 1. The patient was transferred from stretcher to the hospital bed ... Report was given to the patients (sic) care team. Care of the patient was transferred ... Crew Members Personnel Role Certification Level (Named Paramedic #1) Lead EMT-Paramedic ..."

Closed medical record review conducted at The Outer Banks Hospital, Inc. (Hospital A) on 12/18/2018 revealed Patient (PT) #6 was a 13-year-old male who presented to Hospital A's DED on 11/16/2018 at 2311 via ambulance, with triage vital signs of Blood Pressure (BP) 163/102, Temperature (T) 36.8 degrees Celsius, Pulse (P) 118 Respirations (R) 22, and Pulse Oximetry 99 % (percent) on room air. At triage, PT #6 rated his pain at 8 of 10. Review of an ED (Emergency Department) Provider Note electronically signed on 11/17/2018 at 0102 by Medical Doctor (MD) #1 revealed, "TRIAGE CHIEF COMPLAINT ... Ankle Injury pt injured left ankle at trampoline park, as per ems (Emergency Medical Service), pt has obvious deformity ... Patient comes in via EMS with a left ankle splint in place. Family gives me most of information stating he was on a trampoline. And landed cross leg in. (sic) Patient's complaining about left ankle pain. During physical exam. (sic) There was also noted pain to his right ankle ... PHYSICAL EXAM ... EXTREMITIES: +2 pulses noted dorsalis pedis bilateral, bilateral feet are warm, deformity appreciated a (sic) left ankle, with tenderness bilateral malleolus. Right ankle tender at the lateral malleolus. Able to move all of the digits ... XRAY ANKLE 3+ VIEWS RIGHT ... FINDINGS ... There is a Salter II fracture of the distal tibia. There is no dislocation. There is subluxation evident at the growth plate of the distal tibia. Impression ... Salter II fracture of the distal tibia with subluxation of the metaphysis relative to the epiphysis ... XRAY ANKLE 3+ VIEWS LEFT ... FINDINGS: Two views of the left ankle demonstrate displaced oblique/spiral type fractures of the distal tibia and ulna (sic) proximal to the growth plates. The distal tibia fracture likely extends to the growth plate. No gross dislocation of the ankle joint. Talar dome is smooth. Impression ... Displaced oblique/spiral type fractures of the distal tibia and fibula proximal to the growth plates. The distal tibial fracture likely involves the growth plate. No ankle dislocation ... ED COURSE/PLAN: X-rays of the ankles, pain control ... Patient has received 2 mg (milligrams) of Dilaudid. Resting comfortably. I did go back in and see him. While splinted and not moving he is without any pain. I had a discussion with the family there were questionable (Abbreviation for Hospital B) (sic) ... ED Disposition Xfer (transfer) (Named Hospital B) ..." Medications administered to PT #6 during the DED visit included: Dilaudid 1 mg IV and Zofran 4 mg IV on 11/16/2018 at 2327; and Dilaudid 1 mg IV on 11/16/2018 at 2350. Review of an ED Note written by Registered Nurse (RN) #1 on 11/17/2018 at 0106 revealed, "Sugar tong splint applied to pt right extremity, pt tolerated very well." PT #6's vital signs on 11/17/2018 at 0110 were BP154/87, T 36.7 degrees Celsius, P 116, R 22, Pulse Oximetry 98%. On 11/17/2018 at 0120, PT #6 was transported via ambulance to Hospital B. There was no documentaion in the medical record to indicate that the SAM splint had been removed from the patient's left ankle and was adequately evaluated by the provider while Patient #6 was in the ED on 11/16/2018.


Review of a History and Physical written by MD #2, at Hospital B, on 11/18/2018 at 0310 revealed, "...It appears there was delayed (sic) in the transfer and the patient had the right ankle splinted at (Named Hospital A); however the left side remained in the SAM splint. When he was evaluated by the ED physician at (Named Hospital B) new x-rays were ordered and Orthopedics was consulted. The patient was prepped for sedation and closed reduction of his ankle fractures in our Emergency Department ... The SAM splint was removed and there was an area of skin at risk with possible necrosis on the medial side. There was also an area of bruising on the superior part where the splint was pressing on the leg ... We placed a dressing over that and then performed reduction with the assistance of conscious sedation from the ER physician. The right side was also reduced and splinted ... I will plan on having plastics consult on the skin necrosis. We will manage his pain and get him evaluated for definitive surgical management as the skin issues are fully realized." Review of a Consult Report written by MD #3 on 11/17/2018 at 0918 revealed, "...At the time of his arrival, the initially placed SAM splint from (Named City), placed by EMS in the field, was still on the patient's left lower leg and continued present until the patient was seen by the Orthopedic consultant (Named) shortly after 0700 this morning [approximately 9 hours and 30 minutes after SAM Splint application]. Upon taking down the SAM splint and inspecting the lower extremity, there was noted initially a fairly prominent whitish area of skin pressure injury to the anteromedial distal left lower leg, which subsequently improved to an area of marked erythema circumferentially with an early stage I pressure ulceration. There is a concerning, more central smaller area of potentially full thickness pressure injury in the center of this area of skin ischemia ... Impression ... 4.0 x 3.5 cm (centimeter) area of ischemic pressure injury of the skin of dorsomedial distal left lower leg at the site of fracture deformity of the tibial fracture, and almost certainly due to pressure from the overlying SAM splint applied by (Named State) EMS. Note is made that upon removal of the splint, there was no padding below the splint over the fracture deformity. There is a concerning central area 1.5 x 1.5 cm diameter of mottled, likely full thickness, skin injury over the area of the fracture deformity at the left tibia with likely pressure necrosis to develop over the next 5-7 days ..." Review of a Consult Report written by MD #4 on 11/19/2018 at 0944 revealed, "...I evaluated the patient intraoperatively during (Named MD) procedures. She had already made multiple incisions surrounding the ankle on the left side. I evaluated the previously noted pressure sore. This area was noted to have pink up more (sic) and had improved capillary refill. It is beginning to show some signs of de-epithelialization of the superficial epidermis. This most (sic) likely would be a partial thickness pressure sore or grade II to the dermis. Close observation is recommended. I recommended applying Mepilex Silver dressings to the area and avoiding compression over the area ..." Ultimately, PT #6's fracture was surgically reduced, and he was discharged on 11/20/2018 with Orthopedic and Plastic Surgery referrals for follow up. Review of an Office Note written by MD #5 on 12/04/2018 at 1748 revealed, "...Assessment/Plan 1. Necrosis of surgical wound This young man has some necrosis of the anterior skin of the left ankle, which appears to be partial thickness, but does have some eschar which is still adherent. We did some dressing changes ... and I explained to dad that this should be done at least once and perhaps twice daily ... We will plan to see him back in 2 weeks, and we have asked them to send photographs via email in 1 week."

Telephone interview, conducted with Paramedic #1 on 12/19/2018 at 1212, revealed he witnessed the SAM splint to PT #6's left lower extremity being applied by the 2nd Emergency Medical Technician on the call. Interview revealed no additional padding was applied to the extremity or boney prominences prior to the application of the SAM splint.

The 2nd Emergency Medical Technician was unavailable for interview.

Staff interview, conducted with RN #1 on 12/19/2018 at 1059, revealed the SAM splint on PT #6's left lower extremity was placed by EMS, and not removed during the care provided at Hospital A. Interview revealed often field splints are left in place during initial x-rays, and the decision to remove or replace them is evaluated "from there," based on physician discretion. Interview revealed normal process is to check for distal pulses and capillary refill, especially before discharge or directly after application of any splint. Interview revealed with a foot wrapped or covered by a splint pedal pulses would be difficult to evaluate, and RN #1 would mainly rely on capillary refill.

Physician interview, conducted on 12/19/2018 at 1015 with MD #1, revealed the SAM splint on PT #6's left lower extremity was applied by EMS and never removed during the care provided at Hospital A. MD #1 stated there was no open fracture or bleeding from the extremity. EMS was mainly concerned with the left ankle fracture, but MD #1's assessment revealed probable cause for a right ankle fracture as well. Pain medication was administered, and X-rays were ordered. Interview revealed PT #6 could not tolerate the movement necessary for the X-rays, so additional pain medication was administered. Once the X-rays "were back" bilateral ankle fractures were visualized on the x-rays. Interview revealed treatment of the fractures were beyond the capabilities of local orthopedists, as they do not treat fractures in pediatric patients involving the growth plate. Additionally, PT #6's mother requested him to be transported to Hospital B. Interview revealed while the left lower extremity SAM splint was never removed, "the foot was checked for 'cap' (capillary) refill and dorsalis pedis pulses, did not feel it was worth the pain the patient would go through to remove the splint." PT #6 had already received 2 mg of Dilaudid pain medication, which MD #1 felt was the upper limit of pain medication dosage, considering the patient's age. Interview revealed MD #1 did not feel there was any benefit to removing the splint, as it could cause the patient more pain, and another splint would have to be applied prior to transport. MD #1 recalled hearing the receiving physician at Hospital B stating PT #6 would be going into surgery immediately after arrival to Hospital B.

Based on policy review, medical record review, ambulance trip report, manufacturer Splint User quide, and interviews the hospital failed to ensure that stabilizing treatment was provided as required for an individual within the capability of the staff and facilities by failing to adequately evaluate and apply a dressing appropriately between the left ankle and splint prior to transfer for 1 (#6) of 26 sampled patients.

Findings included:

Review of hospital policy titled "EMTALA Information - Medical Screening" effective 01/2018, revealed, "...If an Emergency Medical Condition is detected, Necessary Stabilization Treatment to Stabilize a patient's Emergency Medical Condition shall be rendered in the hospital of an Appropriate Transfer shall be initiated ... Necessary Stabilizing Treatment That medical care necessary to Stabilize an Emergency Medical Condition ... Stabilize With respect to an Emergency Medical Condition, to provide whatever treatment of the condition is necessary to assure, within reasonable medical probability, that no material deterioration is likely to result from (or occur during) the Transfer ... of the individual ..."

Review of manufacturer user guide titled "SAM Splint User's Guide" revealed, "...Ankle Stirrup ... If footwear is removed or whenever the ankle is exposed, place padding above and around the boney prominences on each side of the ankle ..."

Review of an Emergency Medical Services (EMS) ambulance call report written on 11/17/2018 at 0622 by Paramedic #1 revealed, "Date: 11/16/2018 ...Flow Chart ...22:27 IV Therapy 22 ga (gauge); Hand-Right ... 22:30 Fentanyl 75 Micrograms ... Intravenous (IV) ... 22:32 Splint Fx (fracture)/Disloc. (Dislocation) Patient Response: Unchanged; Successful ... 22:53 Fentanyl 25 Micrograms ... IV ... Narrative ... The patient was jumping from the trampoline to the inflated air pit. I was told the patient had done a flip and landed cross legged. The patient states that he heard a pop in his ankle and it began to hurt ... There was an obvious deformity noted to the patients (sic) left ankle. The patient had good PMS (Pulse Motor Sensation) noted distal to the injury. The patients (sic) right leg had an abnormal sensation but there was no pain upon palpation and no deformities noted. The patient had good pulse and motor in the right foot ... The patients (sic) ankle was then splinted with the use of a SAM splint. The patient had good PMS in the patients (sic) foot after splinting ... Upon arriving at the hospital the patient was brought to ER room number 1. The patient was transferred from stretcher to the hospital bed ... Report was given to the patients (sic) care team. Care of the patient was transferred ... Crew Members Personnel Role Certification Level (Named Paramedic #1) Lead EMT-Paramedic ..."

Closed medical record review conducted on 12/18/2018 revealed Patient (PT) #6 was a 13-year-old male who presented to Hospital A's DED on 11/16/2018 at 2311 via ambulance, with triage vital signs of Blood Pressure (BP) 163/102, Temperature (T) 36.8 degrees Celsius, Pulse (P) 118 Respirations (R) 22, and Pulse Oximetry 99 % (percent) on room air. At triage, PT #6 rated his pain at 8 of 10. Review of an ED (Emergency Department) Provider Note electronically signed on 11/17/2018 at 0102 by Medical Doctor (MD) #1 revealed, "TRIAGE CHIEF COMPLAINT ... Ankle Injury pt injured left ankle at trampoline park, as per ems (Emergency Medical Service), pt has obvious deformity ... Patient comes in via EMS with a left ankle splint in place. Family gives me most of information stating he was on a trampoline. And landed cross leg in. (sic) Patient's complaining about left ankle pain. During physical exam. (sic) There was also noted pain to his right ankle ... PHYSICAL EXAM ... EXTREMITIES: +2 pulses noted dorsalis pedis bilateral, bilateral feet are warm, deformity appreciated a (sic) left ankle, with tenderness bilateral malleolus. Right ankle tender at the lateral malleolus. Able to move all of the digits ... XRAY ANKLE 3+ VIEWS RIGHT ... FINDINGS ... There is a Salter II fracture of the distal tibia. There is no dislocation. There is subluxation evident at the growth plate of the distal tibia. Impression ... Salter II fracture of the distal tibia with subluxation of the metaphysis relative to the epiphysis ... XRAY ANKLE 3+ VIEWS LEFT ... FINDINGS: Two views of the left ankle demonstrate displaced oblique/spiral type fractures of the distal tibia and ulna (sic) proximal to the growth plates. The distal tibia fracture likely extends to the growth plate. No gross dislocation of the ankle joint. Talar dome is smooth. Impression ... Displaced oblique/spiral type fractures of the distal tibia and fibula proximal to the growth plates. The distal tibial fracture likely involves the growth plate. No ankle dislocation ... ED COURSE/PLAN: X-rays of the ankles, pain control ... Patient has received 2 mg (milligrams) of Dilaudid. Resting comfortably. I did go back in and see him. While splinted and not moving he is without any pain. I had a discussion with the family there were questionable (Abbreviation for Hospital B) (sic) ... ED Disposition Xfer (transfer) (Named Hospital B) ..." Medications administered to PT #6 during the DED visit included: Dilaudid 1 mg IV and Zofran 4 mg IV on 11/16/2018 at 2327; and Dilaudid 1 mg IV on 11/16/2018 at 2350. Review of an ED Note written by Registered Nurse (RN) #1 on 11/17/2018 at 0106 revealed, "Sugar tong splint applied to pt right extremity, pt tolerated very well." PT #6's vital signs on 11/17/2018 at 0110 were BP154/87, T 36.7 degrees Celsius, P 116, R 22, Pulse Oximetry 98%. On 11/17/2018 at 0120, PT #6 was transported via ambulance to Hospital B.


Review of a History and Physical written by MD #2, at Hospital B, on 11/18/2018 at 0310 revealed, "...It appears there was delayed (sic) in the transfer and the patient had the right ankle splinted at (Named Hospital A); however the left side remained in the SAM splint. When he was evaluated by the ED physician at (Named Hospital B) new x-rays were ordered and Orthopedics was consulted. The patient was prepped for sedation and closed reduction of his ankle fractures in our Emergency Department ... The SAM splint was removed and there was an area of skin at risk with possible necrosis on the medial side. There was also an area of bruising on the superior part where the splint was pressing on the leg ... We placed a dressing over that and then performed reduction with the assistance of conscious sedation from the ER physician. The right side was also reduced and splinted ... I will plan on having plastics consult on the skin necrosis. We will manage his pain and get him evaluated for definitive surgical management as the skin issues are fully realized." Review of a Consult Report written by MD #3 on 11/17/2018 at 0918 revealed, "...At the time of his arrival, the initially placed SAM splint from (Named City), placed by EMS in the field, was still on the patient's left lower leg and continued present until the patient was seen by the Orthopedic consultant (Named) shortly after 0700 this morning [approximately 9 hours and 30 minutes after SAM Splint application]. Upon taking down the SAM splint and inspecting the lower extremity, there was noted initially a fairly prominent whitish area of skin pressure injury to the anteromedial distal left lower leg, which subsequently improved to an area of marked erythema circumferentially with an early stage I pressure ulceration. There is a concerning, more central smaller area of potentially full thickness pressure injury in the center of this area of skin ischemia ... Impression ... 4.0 x 3.5 cm (centimeter) area of ischemic pressure injury of the skin of dorsomedial distal left lower leg at the site of fracture deformity of the tibial fracture, and almost certainly due to pressure from the overlying SAM splint applied by (Named State) EMS. Note is made that upon removal of the splint, there was no padding below the splint over the fracture deformity. There is a concerning central area 1.5 x 1.5 cm diameter of mottled, likely full thickness, skin injury over the area of the fracture deformity at the left tibia with likely pressure necrosis to develop over the next 5-7 days ..." Review of a Consult Report written by MD #4 on 11/19/2018 at 0944 revealed, "...I evaluated the patient intraoperatively during (Named MD) procedures. She had already made multiple incisions surrounding the ankle on the left side. I evaluated the previously noted pressure sore. This area was noted to have pink up more (sic) and had improved capillary refill. It is beginning to show some signs of de-epithelialization of the superficial epidermis. This most (sic) likely would be a partial thickness pressure sore or grade II to the dermis. Close observation is recommended. I recommended applying Mepilex Silver dressings to the area and avoiding compression over the area ..." Ultimately, PT #6's fracture was surgically reduced, and he was discharged on 11/20/2018 with Orthopedic and Plastic Surgery referrals for follow up. Review of an Office Note written by MD #5 on 12/04/2018 at 1748 revealed, "...Assessment/Plan 1. Necrosis of surgical wound This young man has some necrosis of the anterior skin of the left ankle, which appears to be partial thickness, but does have some eschar which is still adherent. We did some dressing changes ... and I explained to dad that this should be done at least once and perhaps twice daily ... We will plan to see him back in 2 weeks, and we have asked them to send photographs via email in 1 week."

Telephone interview, conducted with Paramedic #1 on 12/19/2018 at 1212, revealed he witnessed the SAM splint to PT #6's left lower extremity being applied by the 2nd Emergency Medical Technician on the call. Interview revealed no additional padding was applied to the extremity or boney prominences prior to the application of the SAM splint.

The 2nd Emergency Medical Technician was unavailable for interview.

Staff interview, conducted with RN #1 on 12/19/2018 at 1059, revealed the SAM splint on PT #6's left lower extremity was placed by EMS, and not removed during the care provided at Hospital A. Interview revealed often field splints are left in place during initial x-rays, and the decision to remove or replace them is evaluated "from there," based on physician discretion. Interview revealed normal process is to check for distal pulses and capillary refill, especially before discharge or directly after application of any splint. Interview revealed with a foot wrapped or covered by a splint pedal pulses would be difficult to evaluate, and RN #1 would mainly rely on capillary refill.

Physician interview, conducted on 12/19/2018 at 1015 with MD #1, revealed the SAM splint on PT #6's left lower extremity was applied by EMS and never removed during the care provided at Hospital A. MD #1 stated there was no open fracture or bleeding from the extremity. EMS was mainly concerned with the left ankle fracture, but MD #1's assessment revealed probable cause for a right ankle fracture as well. Pain medication was administered, and X-rays were ordered. Interview revealed PT #6 could not tolerate the movement necessary for the X-rays, so additional pain medication was administered. Once the X-rays "were back" bilateral ankle fractures were visualized on the x-rays. Interview revealed treatment of the fractures were beyond the capabilities of local orthopedists, as they do not treat fractures in pediatric patients involving the growth plate. Additionally, PT #6's mother requested him to be transported to Hospital B. Interview revealed while the left lower extremity SAM splint was never removed, "the foot was checked for 'cap' (capillary) refill and dorsalis pedis pulses, did not feel it was worth the pain the patient would go through to remove the splint." PT #6 had already received 2 mg of Dilaudid pain medication, which MD #1 felt was the upper limit of pain medication dosage, considering the patient's age. Interview revealed MD #1 did not feel there was any benefit to removing the splint, as it could cause the patient more pain, and another splint would have to be applied prior to transport. MD #1 recalled hearing the receiving physician at Hospital B stating PT #6 would be going into surgery immediately after arrival to Hospital B.The facility failed to ensure that stabilizing treatment was provided within the facilities capacity as evidenced by failing to remove the splint and reapplying it with an underlying protective dressing prior to transferring patient #6 on 11/16/2018.

NC00145870