HospitalInspections.org

I. Based on document review and staff interview, the hospital administrative staff failed to ensure Emergency Department (ED) staff followed hospital policies and procedures and provided 1 of 30 patients selected for review, from 12/1/10 to 5/23/11, all available and appropriate stabilizing treatment. The hospital administrative staff identified an average of 213 patients that presented with hand injuries per month.

Failure to follow policies and procedures regarding providing appropriate stabilizing treatment could result in a delay in patients receiving care, potentially resulting in avoidable disability, or loss of life or limb.

Findings include:

1. Review of the "Medical Staff Bylaws", adopted 12/15/10, revealed in part, "The [Medical Executive Committee] designates specific Clinical Department/specialties to develop an on call [sic] roster to provide for the emergent medical screening, stabilization, and/or transfer of ... patients."

2. Review of the policy "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", effective 8/09, revealed in part, "The On-call Roster will include Core Services readily available to facilitate emergency medical screening." Further review of the policy revealed the Core Services Roster included Plastic Surgery and Hand Surgery.

3. Review of an untitled, undated, list of surgical procedures from the hospital's operating rooms revealed surgeons previously on the hand surgery on-call list performed surgery on 5 patients listed as "Emergency" patient types from 12/1/10 to 5/25/11.

4. Review of Patient #1's medical record revealed Patient #1 presented to the ED on 5/15/11 at 9:50 PM, with a complaint of an injury to the left thumb. At 10:03 PM, Registered Nurse (RN) B documented on the Interdisciplinary Record, "[cut left] thumb couple of days ago. Now swollen and painful and red. [sic]" At 11:30 PM, Physician's Assistant (PA) C assessed Patient #1, and documented Patient #1 had swelling in the left thumb, an infection in the left thumb, along with red streaks running up the left arm, that indicated an infection was spreading.

At 1:10 AM, PA C contacted Hand Surgeon D. PA C documented Hand Surgeon D could not operate on Patient #1 until the next afternoon, and Patient #1 required surgery before Hand Surgeon D could perform the surgery. Hand Surgeon D instructed PA C to attempt to contact another hand surgeon.

At 1:15 AM, PA C contacted Hand Surgeon E's nurse. Hand Surgeon E's nurse stated Hand Surgeon E could not provide care to Patient #1, since Hand Surgeon E had surgery scheduled at 6:30 AM that morning.

At 1:20 AM, PA C contacted Hand Surgeon F's office manager. Hand Surgeon F's office manager stated Hand Surgeon F was out of town until the next afternoon.

At 1:41 AM, PA C contacted a hand surgeon at Hospital A. The hand surgeon at Hospital A agreed to accept Patient #1 if PA C could not find an accepting hand surgeon.

At 1:55 AM, PA C contacted Hand Surgeon G. Hand Surgeon G stated they could not provide care to Patient #1, since Hand Surgeon G was scheduled to see patients in their office all day.

At 2:15 AM, PA C informed Patient #1 of the need to transfer them to Hospital A. At 3:00 AM, hospital staff transferred Patient #1 to Hospital A.

5. Review of the on-call schedule for Hand Surgeons from 4/1/06 to 12/1/10, revealed the hospital maintained an active list of surgeons available for consultation in the Emergency Department.

6. Review of a letter from the President of Mercy Hospital to the Chief Executive Officer of the physician group providing on-call coverage for hand surgeons, dated 8/10/10, revealed Mercy Hospital terminated the on-call contract for hand surgeons as of 12/1/10.

7. Review of on-call schedules from 12/1/10 to 6/1/11 revealed the on-call schedules lacked a on-call schedule for hand surgeons.

8. During an interview on 5/24/11 at 1:07 PM, the Chief Medical Officer (CMO) stated the hospital had stopped paying hand surgeons to provide on-call coverage after 12/1/10. The CMO stated the hand surgeons had not provided an on-call schedule after 12/1/10. About 2 months prior (April 2011), Hand Surgeon D had agreed to provide on-call coverage for the ED while the hospital attempted to create a hand surgery on-call schedule that included the 7 hand surgeons previously providing on-call availability, and would also include Hand Surgeon D.

II. Based on document review and staff interview, the hospital administration failed to provide all available and appropriate stabilizing treatment for 1 of 28 patients, selected for review, from 5/26/11 to 8/14/11, that presented to the Emergency Department (ED), and requested care. The hospital administrative staff identified an average of 7726 patients that presented to the ED for treatment per month.

Failure to follow policies and procedures regarding providing appropriate stabilizing treatment could result in a delay in patients receiving care, potentially resulting in avoidable disability, or loss of life or limb.

Findings include:

1. Review of the policy "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", revised 07/11, revealed in part, "The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition..."

2. Review of the "MERCY MEDICAL CENTER - DES MOINES MEDICAL STAFF BYLAWS", reviewed 7/11, revealed in part, "Those patients who have urgent or emergency medical needs will be evaluated promptly and treated ..."

3. Review of Patient #45's medical record revealed Patient #45 presented to the ED on 7/4/11 at 11:48 AM. At 11:52 AM, Registered Nurse (RN) H documented, on the Interdisciplinary Record Page 1, Patient #45 complained of "[Right] foot pain. [Diagnosed] tendonitis. [Both] shoulder pain [after] using [a] walker. No fall."

At 12:30 PM, RN I documented, on the Interdisciplinary Record Page 1, Patient #45 "felt feverish" and Patient #45 had a light red discoloration to both ankles. RN I documented Patient #45 complained it hurt to bend over, had pulled the hamstrings in both legs, and had groin tendonitis. RN I also documented Patient #45 had a past medical history that included arthritis.

At 12:55 PM, Emergency Physician J examined Patient #45. Emergency Physician J documented in the ED Physician Notes that Patient #45 complained of right foot pain, without a history of injury, and believed the pain was secondary to right groin tendonitis. Emergency Physician J documented Patient #45 had swelling in the feet, but did not notice any redness in the feet. Emergency Physician J also documented Patient #45 had tenderness on the top of the right foot, and pain limited Patient #45 from moving both feet. Emergency Physician J diagnosed Patient #45 with arthritis of the right foot, and ordered the ED nursing staff to discharge Patient #45.

At 3:30 PM, RN K documented, on the Interdisciplinary Record Page 2, that Patient #45 "ambulated a short distance [with] assistance of wheelchair. [Patient] tolerated fair, feet hurt to walk on.... [Follow up with] arthritis patient.... [Patient] concerned about red areas going up leg. [Emergency Physician J's name] aware - orders to have [patient] follow up with arthritis doctor." RN K then discharged Patient #45 home at 3:48 PM.

4. During an interview on 8/16/11 at 4:15 PM, Emergency Physician J stated they did not specifically look at Patient #45's feet for redness. Instead they only looked at Patient #45's overall legs. Emergency Physician J stated they asked the nurse to take Patient #45 for "a test drive" and have Patient #45 try to walk with the assistance of a wheelchair. If Patient #45 could walk with a wheelchair for support, Patient #45 was stable for discharge. Patient #45 had a history of arthritis, and Emergency Physician J assumed the shoulder pain was from the arthritis, and did not assess Patient #45's shoulders.

5. During an interview on 8/16/11 at 2:05 PM, RN K stated Patient #45's family inquired about the redness on Patient #45's feet. RN K thought Patient #45 had a simple foot compliant, and the little red bumps on Patient #45's feet didn't look like it needed medical attention. RN K had Patient #45 walk in the ED, holding a wheelchair for support. Patient #45 had arthritis, but could walk without dragging the foot, and didn't have to stop walking because of foot problems. Because Patient #45 didn't have problems walking with the wheelchair, RN K felt Patient #45 was safe to discharge home.

6. Patient #45's medical record revealed hospital staff admitted Patient #45 directly to the hospital on 7/6/2011. Patient #45's admitting diagnosis was cellulitis of the right leg, and uncontrolled pain. A Surgeon's Note from 7/13/11 at 6:10 PM revealed Patient #45's admission was for an infection that started in the right lower leg, and a blood culture showed bacteria in Patient #45's blood. The medical record showed that Patient #45 died on 7/14/11 as a result of the bacterial infection invading the blood stream.

7. According to the statutorily mandated Quality Improvement Organization's physician peer review, Patient #45 did not receive an appropriate medical screening exam on 7/4/11 to determine the cause of Patient #45's foot pain, because the Emergency Department physician failed to consider that an infection caused Patient #45's foot pain.

Based on document review and staff interview, the hospital administrative staff failed to maintain a list of on-call hand surgeons (1 of 1 hand call schedule) available for evaluation and treatment of patients that presented to the Emergency Department (ED) requesting evaluation and treatment of medical conditions involving the hand. The hospital administrative staff identified an average of 213 patients that presented with hand injuries per month.

Failure to maintain a list of on-call hand surgeons available for consultation could potentially result in patients not receiving adequate evaluation and stabilizing treatment, or could potentially result in the hospital transferring patients to another facility with the same capacity, and delaying definitive treatment.

Findings include:

1. Review of the policy "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", effective 8/09, revealed in part, "The On-call Roster will include Core Services readily available to facilitate emergency medical screening." Further review of the policy in exhibit G revealed the Core Services Roster included "Plastic/Hand" [surgeons] and subspecialties of psychiatry and cardiothoracic surgeon.

2. Review of on-call schedules dated from 12/1/10 to 6/1/11, posted in the Emergency Department, revealed the posted on-call schedules did not include plastic/hand (surgeons), cardiothoracic surgeons, and psychiatry specialties.

During an interview on 5/25/11 at 10:45 AM, the Administrative Secretary reported the hospital did not maintain an on-call list for cardiothoracic surgery. Review of Mercy Medical Center's web site at mercydesmoines.org revealed the hospital had cardiovascular surgeons on staff that performed 1200 heart operations annually.

Review of Mercy Medical Center's web site at mercydesmoines.org/behaviorhealth/index.cfm revealed the hospital provided urgent/emergent assessments.

3. During an interview on 6/27/11 at 1:43 PM, Hand Surgeon A stated the hospital lacked a list of on-call hand surgeons from 12/1/10 to present. Originally, 15 hand surgeons started providing on-call availability in 2004. However, by 11/1/10, only 7 hand surgeons provided on-call availability. Mercy hospital decided to stop paying hand surgeons for on-call availability, and the hand surgeons stopped providing on-call availability.

4. Review of an email from the CMO to the Emergency Department Medical Directors, dated 5/17/11, revealed in part, "Until further notice if an [emergency] Hand referral is necessary please call [Hand Surgeon D's name] per our previous conversations. As you know [s/he] has agreed to take hand calls until we can have a formalized call schedule."

5. Review of the Emergency Department's May Orthopaedic EMTALA West on-call schedule showed, Hand Surgeon G was the on-call hand surgeon May 15, 2011.

6. Patient #1 presented to the ED on 5/15/11 at 9:50 PM, with an injury to the left thumb. At 11:30 PM, Physician's Assistant (PA) C assessed Patient #1 and documented the Patient had an infection in the left thumb that was spreading. At 1:10 AM (5/16/11), PA C contacted Plastic/Hand Surgeon D and documented the surgeon could not operate until the next afternoon, and instructed PA C to attempt to contact another hand surgeon because the Patient required surgery before the next afternoon. At 1:15 AM, PA C contacted Hand Surgeon E's nurse. Hand Surgeon E's nurse stated the surgeon could not provide care because he had surgery scheduled at 6:30 that morning. At 1:20 AM, PA C contacted Hand Surgeon F's office manager. Hand Surgeon F's office manager stated the surgeon was out of town until the next afternoon. At 1:41 AM, PA C contacted a hand surgeon at Hospital A. The hand surgeon at Hospital A agreed to accept the Patient if PA C could not find an accepting hand surgeon. At 3:00 AM, hospital staff transferred the Patient to Hospital A.

7. OR logs dated from November 2010 through April 2011 showed that 8 orthopedic surgeons, on staff at Mercy Medical Center, with the necessary skill sets, had performed hand surgeries in the hospital OR during this timeframe.

II. Based on document review and staff interview, the hospital administration failed to provide all available and appropriate stabilizing treatment for 1 of 28 patients, selected for review, from 5/26/11 to 8/14/11, that presented to the Emergency Department (ED), and requested care. The hospital administrative staff identified an average of 7726 patients that presented to the ED for treatment per month.

Failure to provide appropriate stabilizing treatment could result in a delay in patients receiving care, potentially resulting in avoidable disability, or loss of life or limb.

Findings include:

1. Review of the policy "EMTALA: The Treatment and Transfer of Individuals Who Request Emergency Medical Services", revised 07/11, revealed in part, "The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition..."

2. Review of Patient #45's medical record revealed Patient #45 presented to the ED on 7/4/11 at 11:48 AM. At 11:52 AM, Registered Nurse (RN) H documented, on the Interdisciplinary Record Page 1, Patient #45 complained of "[Right] foot pain. [Diagnosed] tendonitis. [Both] shoulder pain [after] using [a] walker. No fall."

At 12:30 PM, RN I documented, on the Interdisciplinary Record Page 1, Patient #45 "felt feverish" and Patient #45 had a light red discoloration to both ankles. RN I documented Patient #45 complained it hurt to bend over, had pulled the hamstrings in both legs, and had groin tendonitis. RN I also documented Patient #45 had a past medical history that included arthritis.

At 12:55 PM, Emergency Physician J examined Patient #45. Emergency Physician J documented in the ED Physician Notes that Patient #45 complained of right foot pain, without a history of injury, and believed the pain was secondary to right groin tendonitis. Emergency Physician J documented Patient #45 had swelling in the feet, but did not notice any redness in the feet. Emergency Physician J also documented Patient #45 had tenderness on the top of the right foot, and pain limited Patient #45 from moving both feet. Emergency Physician J diagnosed Patient #45 with arthritis of the right foot, and ordered the ED nursing staff to discharge Patient #45.

At 3:30 PM, RN K documented, on the Interdisciplinary Record Page 2, that Patient #45 "ambulated a short distance [with] assistance of wheelchair. [Patient] tolerated fair, feet hurt to walk on.... [Follow up with] arthritis patient.... [Patient] concerned about red areas going up leg. [Emergency Physician J's name] aware - orders to have [patient] follow up with arthritis doctor." RN K then discharged Patient #45 home at 3:48 PM.

3. During an interview on 8/16/11 at 4:15 PM, Emergency Physician J stated they did not specifically look at Patient #45's feet for redness. Instead they only looked at Patient #45's overall legs. Emergency Physician J stated they asked the nurse to take Patient #45 for "a test drive" and have Patient #45 try to walk with the assistance of a wheelchair. If Patient #45 could walk with a wheelchair for support, Patient #45 was stable for discharge. Patient #45 had a history of arthritis, and Emergency Physician J assumed the shoulder pain was from the arthritis, and did not assess Patient #45's shoulders.

4. During an interview on 8/16/11 at 2:05 PM, RN K stated Patient #45's family inquired about the redness on Patient #45's feet. RN K thought Patient #45 had a simple foot compliant, and the little red bumps on Patient #45's feet didn't look like it needed medical attention. RN K had Patient #45 walk in the ED, holding a wheelchair for support. Patient #45 had arthritis, but could walk without dragging the foot, and didn't have to stop walking because of foot problems. Because Patient #45 didn't have problems walking with the wheelchair, RN K felt Patient #45 was safe to discharge home.

5. Patient #45's medical record revealed hospital staff admitted Patient #45 directly to the hospital on 7/6/2011. Patient #45 ' s admitting diagnosis was cellulitis of the right leg, and uncontrolled pain. A Surgeon's Note from 7/13/11 at 6:10 PM revealed Patient #45 ' s admission was for an infection that started in the right lower leg, and a blood culture showed bacteria in Patient #45's blood. The medical record showed that Patient #45 died on 7/14/11 as a result of the bacterial infection invading the blood stream.

6. According to the statutorily mandated Quality Improvement Organization's physician peer review, Patient #45 did not receive an appropriate medical screening exam on 7/4/11 to determine the cause of Patient #45's foot pain, because the Emergency Department physician failed to consider that an infection caused Patient #45's foot pain.

Based on document review and staff interview, the hospital administration failed to provide all available and appropriate stabilizing treatment for 1 of 30 patients, selected for review, from 12/1/10 to 5/25/11, that presented to the Emergency Department (ED), and requested care. The hospital administrative staff identified an average of 213 patients that presented with hand injuries per month.

Failure to provide appropriate stabilizing treatment could result in a delay in patients receiving care, potentially resulting in avoidable disability, or loss of life or limb.

Findings include:

1. Review of Patient #1's medical record revealed Patient #1 presented to the ED on 5/15/11 at 9:50 PM, with a complaint of an injury to the left thumb. At 10:03 PM, Registered Nurse (RN) B documented on the Interdisciplinary Record, "[cut left] thumb couple of days ago. Now swollen and painful and red. [sic]" At 11:30 PM, Physician's Assistant (PA) C assessed Patient #1, and documented Patient #1 had swelling in the left thumb, an infection in the left thumb, along with red streaks running up the left arm, indicating an infection was spreading. At 1:10 AM (5/16/11), PA C contacted Hand Surgeon D. PA C documented Hand Surgeon D could not operate on Patient #1 until the next afternoon, and Patient #1 required surgery before Hand Surgeon D could perform the surgery. Hand Surgeon D instructed PA C to attempt to contact another hand surgeon. At 1:15 AM, PA C contacted Hand Surgeon E's nurse. Hand Surgeon E's nurse stated Hand Surgeon E could not provide care to Patient #1, since Hand Surgeon E had surgery scheduled at 6:30 AM that morning. At 1:20 AM, PA C contacted Hand Surgeon F's office manager. Hand Surgeon F's office manager stated Hand Surgeon F was out of town until the next afternoon. At 1:41 AM, PA C contacted a hand surgeon at Hospital A. The hand surgeon at Hospital A agreed to accept Patient #1 if PA C could not find an accepting hand surgeon. At 2:15 AM, PA C informed Patient #1 of the need to transfer them to Hospital A. At 3:00 AM, hospital staff transferred Patient #1 to Hospital A.

2. The medical record did not contain evidence that PA C attempted to contact either of the 2 orthopedic surgeons listed on the ED's May 15, 2011 "Orthopedic Trauma Schedule". Review of Orthopedic Trauma Surgeon L and M's "Delineation of Privileges" documents revealed the core Orthopedic privileges included the "Management of infectious and inflammations of bones, joints, and tendon sheaths." Further review revealed Orthopedic Trauma Surgeon L and M, on-call to the ED at 7:00 AM on 5/15/11 to 7:00 AM on 5/16/11, had previous experience in performing hand surgeries as recently as August 2010.

3. During an interview on 5/24/11 at 1:07 PM, the Chief Medical Officer (CMO) stated the hospital had stopped paying hand surgeons to provide on-call coverage after 12/1/10. The CMO stated the hand surgeons had not provided an on-call schedule after 12/1/10.

4. Review of Patient #1's medical record from Hospital A revealed Patient #1 arrived at Hospital A at 3:10 AM. At 5:05 AM, Patient #1 underwent surgery for incision and drainage of the left thumb.