HospitalInspections.org

Based on medical record review and interview the facility failed to ensure complete and appropriate care of an upper extremity injury for one of thirty two emergency department patients (Patient #10). Specifically, one of thirty two emergency department patients did not receive an x-ray which resulted in an undiagnosed fracture by the emergency department physician (Patient #10).
The findings included:
Thirty two electronic medical records were reviewed on March 9, 2015 and March 10, 2015. Patient #10's electronic medical record was reviewed beginning on March 9, 2015 at approximately 10:40 am. A copy of Patient #10 's medical record was requested on March 9, 2015 during the review. A copy of Patient #10 's medical record was received on March 9, 2015 at approximately 3:00 pm. The medical record of Patient #10 was reviewed for a second time on March 9, 2015 beginning at 5:30 pm.
Patient #10 was brought to the Emergency Department by rescue squad on January 14, 2015 at approximately 10:16 pm. The Emergency Services paramedic's documentation dated 01/14/2015 at 10:00 pm states "arrived to find the patient (reference to Patient #10) sitting in a chair at the gym. The patient (reference to Patient #10) was throwing a dodge ball with his/her left continuously when he/she suffered significant pain in his/her left upper arm." Documentation by the paramedic states Patient #10 "denied being struck by another person." Documentation by the paramedic indicates Patient #10 did not suffer any loss of consciousness (LOC) or fall. The paramedic's documentation states Patient #10 denied all pain except "humeral pain just above his/her left elbow." Further documentation by the paramedic states no swelling or discoloration of the left upper extremity. The narrative note by the paramedic states Patient #10 complained of 2/10 pain in his/her arm while it was resting in his/her position of comfort (against the chest) however when he/she attempted to move his/her arm it increased the pain to 9/10. No notations by the paramedic indicated a change in the color, pulses, or sensation of Patient #10's left arm. Documentation on the Emergency Medical Services (EMS) Patient Care Report (page 1) states chief complaint "fracture/dislocation."
Documented arrival time of Patient #10 to the emergency department on January 14, 2015 is 10:16 pm. Patient #10's triage was performed by Staff #11 at 10:18 pm on January 14, 2015. Documentation in the medical record of Patient #10 dated January 14, 2015 indicates the patient was seen by the emergency department physician at 10:22 pm. Documentation by Staff #11 states Patient #10 received a Triage Emergency Severity Index (ESI) of Level 3. According to the U. S. Department of Health and Human Service Agency for Healthcare Research and Quality Emergency the Emergency Severity Index (ESI) is "a simple to use, five-level triage algorithm that categorizes emergency department patients by evaluating both patient acuity, and the resources needed. ESI levels 3, 4, and 5 are differentiated by the nurse's determination of how many resources are needed to make a patient disposition. Those patients who are expected to need two or more resources are designated as ESI level 3."
The triage policy for the facility was requested and received on March 10, 2015 at approximately 8:00 am. A review of the policy titled "Triage" indicates the facility classifies patients into five triage categories "utilizing the Canadian CTAS system to assign acuity" which includes resuscitation, emergent, urgent, less urgent, and non urgent. Of note the facility's electronic medical record lists triage priority scale under the ESI category documentation.
Staff #11 was interviewed on March 11, 2015 at 7:15 am. Staff #11 verified he/she was the triage nurse for Patient #10 and cared for Patient #10 while in the emergency department. Staff #11 stated "a priority score of 3 means the doctor needs to see the patient within about ten minutes." Documentation by Staff #11 in Patient #10's electronic medical record states Patient #10 was alert and oriented times three. Documentation by Staff #11 in Patient #10's medical record states Patient #10's "injury occurred 45 minutes ago and he/she was throwing a dodge ball and felt a pop in the left bicep." Further documentation dated January 14, 2015 at 10:24 pm by Staff #11 indicates Patient #10 was complaining of 4/10 pain in the left bicep area. Staff #11 documented "a small knot was present" and Patient #10 "had limited range of motion due to pain." Notation was made by Staff #11 pertaining to the presence of positive pulses in Patient #10's left upper extremity. Documentation of a complete assessment of Patient #10 on January 14, 2015 by Staff #11 was found.
Staff #11 documented in the medical record of Patient #10 on January 14, 2015 at 10:24 pm under the "Subjective Assessment" Patient #10 stated he/she was playing dodge ball and went to throw the ball and "felt a huge pop in the arm and it hurts to move it."
Documentation by Staff #11 in the electronic medical record of Patient #10 at 10:30 pm on January 14, 2015 under the "Extremity Assessment" notes the mechanism of injury as "change of position/throwing ball." Further documentation states "extremity discomfort and decreased range of motion." Documentation of skin changes, pulses, and sensation of the left upper extremity of Patient #10 by Staff #11 reveal no abnormalities. Documentation by Staff #11 indicates ice and elevation of Patient #10's arm was done per medical doctor (MD) order at 10:35 pm. Documentation by Staff #11 states a left sling and ice was applied per MD order at 10:47 pm. Documentation by Staff #11 at 10:47 pm on January 14, 2015 states Toradol 10 mg by mouth (po) and Oxycodone 5 mg/Tylenol 325 mg tablet po was administered to Patient #10 for pain. Toradol according to Drugs.com is "a nonsteroidal anti-inflammatory drug (NSAIDS). It works by reducing hormones that cause inflammation and pain in the body." Oxycodone and Acetaminophen (Percocet) according to Drugs.com is "a combination medicine used to relieve moderate to severe pain." Percocet is a narcotic.
Documentation in the electronic medical record of Patient #10 under HPI (history of present illness) on January 14, 2015 at 10:22 pm by Staff #19 states "arm injury, patient with sudden onset of pain within the belly of the bicep while throwing during a dodge ball match." He/she "felt and heard a pop at the onset of pain. No lump or swelling reported." Documentation by Staff #19 states mechanism of injury "throwing a ball." Staff #19's documentation states Patient #10 reported a pain level of 4/10 in the left arm. Documentation by Staff #19 states "pain exacerbated by flexion/extension at the elbow and movement of the bicep." Further documentation by Staff #19 states no numbness or tingling of Patient #10 ' s left upper extremity. Physical examination documentation by Staff #19 states under the category titled "Arm/shoulder: tender to palpitation within the belly of the bicep. Limited flexion/extension at the elbow due to bicep pain. No palpable mass or deformity. No physical evidence of complete tendon rupture. Shoulder is normal." Documentation by Staff #19 indicates Patient #10's forearm/elbow, wrist, and hand were all normal. No documentation of a small knot noted (previously noted by Staff #11) on the left arm of Patient #10 by Staff #19.
Documentation on January 14, 2015 by Staff #19 indicates the medical orders for Patient #10 included ice, elevation, and a sling to the left arm. Medications ordered included Toradol 10 mg po and Percocet for pain. No entry was documented under the title "Clinical Impression" by Staff #19 on January 14, 2015. Documentation by Staff #19 on January 14, 2015 at 10:44 pm was found under "Primary Impression" which states "biceps muscle tear."
No documentation was found in Patient #10's electronic medical record the patient had any radiology studies done on January 14, 2015.
Documentation by Staff #11 states Patient #10 was discharged at 11:03 pm with discharge instructions and two prescriptions (Toradol and Percocet) for pain. Documentation by Staff #11 indicates Patient #10 was advised to make an appointment to see orthopedics in 3 to 5 days. A copy of Patient #10's discharge instructions was reviewed on March 10, 2015 at approximately 3:00 pm. The discharge instructions were titled "Strain."
Staff #11 was interviewed on March 10, 2015 at 7:15 am. Staff #11 verified during interview he/she felt a small knot on Patient #10 ' s left upper arm. Staff #11 stated Patient #10 was having trouble with flexion and extension of his/her left arm. When asked by the surveyor if a patient who fractures an arm will sometimes hear a popping sound Staff #11 stated "yes, fractures will pop." Staff #11 stated not all patients with fractures will complain of a pop. Staff #11 confirmed that Patient #10 did not have any x-rays prior to discharge.
Staff #19 was interviewed by speaker phone in the presence of Staff #1 on March 10, 2015 at approximately 5:45 pm. Staff #19 verified he/she provided medical care to Patient #10 on January 14, 2015 in the Emergency Department at the facility named in the complaint. Staff #19 stated Patient #10 had sudden pain in the arm while throwing a ball and heard a pop. Staff #19 stated Patient #10 could move his/her arm and had full range of motion. Staff #19 stated he/she remembered Patient #10 "had pain which was exacerbated with flexion/extension at the elbow." Staff #19 stated the bicep area was tender to palpitation. Staff #19 stated he/she thought the patient (reference to Patient #10) had a bicep muscle tear or strain. Staff #19 stated he/she treated Patient #10 "conservatively but stressed the importance of following up with orthopedics." Staff #19 stated he/she thought about a fracture but Patient #10 was young and healthy and the mechanism of injury was throwing a ball. Staff #19 stated he/she is "generally liberal with obtaining x-rays." Staff #19 verified he/she did not order an x-ray for Patient #10's injured arm on January 14, 2015 while in the emergency department.
Eight physician (including Staff #12 and Staff #19) credential files were reviewed on March 10, 2015 at approximately 9:15 am. All necessary documentation was available for review. All physician credentials were up to date.
Documentation in Patient #10's medical record dated January 19, 2015 from the follow-up visit to the orthopedic specialist was reviewed on March 10, 2015. The documentation by Staff #7 under the section titled "Brief History" states "He/she (reference to Patient #10) was playing dodge ball a couple of days ago and he/she threw the dodge ball and felt a pop in his/her arm. He/she went to the hospital. No x-rays were taken. He/she was diagnosed with a biceps tendon tear and sent to me for follow up in a sling." Documentation of Patient #10's physical examination by Staff #7 states he/she "has a notable amount of bruising over the medial side of the arm and the antecubital fossa (triangular cavity of the elbow that contains a tendon of the biceps, the median nerve, and the brachial artery). His/her arm is grossly swollen." Documentation by Staff #7 reveals x-rays were obtained of Patient #10's left arm during the orthopedic follow up office visit on January 19, 2015. Documentation by Staff #7 states x-rays including AP (anterior/posterior) and lateral of elbow as well as AP and lateral of the humeral (long bone in the arm) shaft were obtained. Documentation by Staff #7 states he/she "has got a distal third humeral shaft spiral fracture with some displacement and slight varus (bent inward) angualtion." According to Orthopedics One.com "humeral shaft fractures are defined as fractures in which the major fracture line occurs distal to the insertion of the pectoralis major (anterior chest muscle) and proximal to the supracondylar ridge (either of two ridges above the condyle of the humerus). The fracture is usually described as open or closed, by the location within the humeral shaft (proximal, middle, or distal third) and overall character of the fracture pattern (transverse, oblique, or spiral)." According to Wheeless ' Textbook of Orthopedics "torsion force will result in a spiral fracture." Documentation by Staff #7 indicates the treatments discussed with Patient #10 and his/her parents were Sarmiento bracing (a brace used to immobilize humeral shaft fractures) or open reduction and internal fixation (a type of surgery used to fix broken bones). Documentation by Staff #7 on January 19, 2015 indicated Patient #10 elected to have the open reduction and internal fixation (ORIF) because of the "long bracing period of time." Further documentation by Staff #7 indicated the surgical procedure would be scheduled as soon as possible. Staff #7 stated he/she "needs to ice this and use the compression sleeve as much as possible."
A copy of the electronic medical record of Patient #10 dated January 27, 2015 was received and reviewed on March 9, 2015. Documentation by Staff #7 indicates Patient #10 underwent surgery on January 27, 2015 for an Open Reduction Internal Fixation (ORIF) of the left humeral shaft fracture. Documentation by Staff #7 in the section titled "Description of the Procedure" states "I placed 2 lag screws across the fracture securing the anatomic reduction. I slid a long Synthes (type of orthopedic trauma hardware) posterolateral locking plate, underneath the proximal radial nerve (large nerve in the arm). The radial nerve expansion was very broad across the posterior aspect of the humerus and almost parallel to the shaft of the bone, so that actually traversed quite a distance from proximal to distal along the humeral shaft. This caused me to use a much longer plate than I normally would with 3 cortical screws proximal to the fracture site and multiple cortical and locking screws distal to the fracture site."
Documentation by Staff #7 in Patient #10's electronic medical record indicates Patient #10 was discharged on January 27, 2015. Discharge plan documented by Staff #7 states he/she "will be in a sling for comfort." Documentation by Staff #7 states Patient #10 "will be in a compression sleeve to control edema and immediately begin range of motion exercises." Further documentation by Staff #7 states a follow up appointment for Patient #10 on Friday or Monday (no dates recorded) to put him/her on the edema (swelling) control sleeve and glove.
Staff #7 was interviewed via speaker phone on March 10, 2015 at approximately 10:45 am. Staff #1, Staff #6, Staff #3, and Staff #12 were present during the interview. Staff #7 confirmed he/she cared for Patient #10 during the follow up orthopedic visit on January 19, 2015. Staff #7 stated he/she remembered Patient #10 (called patient by name). Staff #7 stated Patient #10 had been to the emergency department (reference to facility named in the complaint) with an injury to the arm. Initially, Staff #7 stated the injury was sustained he/she thought playing baseball but later stated he/she remembered it was dodge ball. Staff #7 stated Patient #10 reported no x-rays were done while in the emergency department. Staff #7 stated Patient #10's left arm was "very swollen and had a lot of bruising" on January 19, 2015. Staff #7 stated he/she ordered x-rays (4 views) and a left humeral shaft fracture was found. Staff #7 stated "this was a fracture that was missed. X-rays should have been taken." Staff #7 stated this type of injury is somewhat "unusual but have seen a handful of these types of injuries." Staff #7 stated after being asked by the surveyor if x-rays were taken the night of the injury would the treatment be different for Patient #10. Staff #7 stated "no the treatment would have been the same. No harm was done to the patient. No difference in the treatment but x-rays should have been taken. This was a misdiagnosis, thinking it was a bicep tear. A bicep tear would be an unusual injury for a patient of his/her age."
Staff #12 was interviewed on March 10, 2015 at approximately 10:25 am. Staff #12 confirmed he/she spoke with Patient #10 and explained why Staff #19 did not do an x-ray. Staff #12 confirmed he/she "waived part of the bill." Staff #12 stated he/she spoke directly with Staff #19 after reviewing the medical record of Patient #10. Staff #12 stated it made more sense to him/her after speaking with Staff #19 pertaining to why no x-ray was taken. Staff #12 stated Patient #10 was a young healthy patient who had a non traumatic injury to the arm and although had pain had full range of motion. Staff #12 was asked by the surveyor if a torn bicep is a common injury in a 21 year old. Staff #12 stated "it is not a common injury in a 21 year old." Staff #12 was asked by the surveyor about the significance of the popping Patient #10 described to the emergency department staff. Staff #12 stated popping is a common complaint with orthopedic injuries in general. Staff #12 stated popping can happen for a lot of reasons. Staff #12 stated "the popping is more suspicious for a fracture." Staff #12 confirmed the emergency department has a "Long Bone Fracture Protocol" which is used for obvious fractures and pertains to pain management. A copy of the protocol was requested and reviewed on March 10, 2015. Staff #12 stated the decision to x-ray is determined by the physician based on physical examination, mechanism of injury, history, pain, and range of motion.
Documentation by Staff #12 to Staff #14 on February 27, 2015 pertaining to the complaint states he/she (reference to Patient #10) "had no blunt trauma of any kind and full painless range of motion at every joint in the affected arm" which lead to no imaging by the emergency department medical doctor.
According to the Mayo Clinic.com normal range of motion is defined as "the full movement potential of a joint, usually its range of flexion and extension."
Documentation by the paramedic on January 14, 2015 stated Patient #10 had 9/10 pain when moving left arm. Documentation by Staff #11 on January 14, 2015 at 10:24 pm stated Patient #10's left arm "had limited range of motion." Documentation by Staff #19 on January 14, 2015 at 10:22 pm states "limited flexion/extension at the elbow due to bicep pain. Pain in the left arm exacerbated by flexion/extension at the elbow and movement of the bicep."