HospitalInspections.org

Based on document review, policy review, medical record review and interview, it was determined the hospital failed to ensure the Emergency Department (ED) provided an adequate Medical Screening Examination (MSE) to determine if an emergency medical condition existed. Failure of the hospital to provide an appropriate MSE resulted in the inability to have a definitive determination of an emergency medical condition, failure to provide treatment for such conditions based on the MSE and failure to ensure patients were stabilized prior to being discharged from the ED for 1 of 25 (Patient #21 when he sought emergency care on 9/28/10) sampled patients.

Refer to findings in deficiency A2406 and A2407.

Based on document review, medical record review and interview, it was determined the hospital failed to ensure all patients (Pt) presenting to the Emergency Department (ED) seeking medical care received an adequate Medical Screening Examination (MSE) to determine if an emergency medical condition existed. Failure to ensure adequate assessments were performed led to the patient being released without having determined the cause of their illness and without having received treatment and stabilization for 1 of 25 (Patient #21) sampled patients. Patient #21 sought medical care on 9/28/10.

The findings included:

1. Review of the hospital's policy, "Adult Emergency Dept [Department] Emergency Screening, Stabilization and Transfer ..." revealed, "...Purpose: To establish procedures for the medical screening of patients presenting to the ED to determine whether an emergency medical condition exists... screening shall be conducted to determine whether the individual has an 'Emergency Medical Condition' which is defined under federal law as: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in... Placing the health of the individual... in serious jeopardy... Serious impairment to bodily functions... Serious dysfunction of any bodily organ or part..."

2. Review of the hospital's policy, "Standards of Care" revealed, "Purpose: To define minimal standards of care for each patient who presents to the Emergency Department (ED) for treatment... The attending physician is accountable for all medical care rendered in the department... The plan of care will be collaborative effort between physicians and Emergency Department nursing staff and will be documented in the medical record."

3. Review of a written document submitted by the facility on 7/19/12 at 4:03 PM in answer to questions concerning Observation orders for Pt #21 revealed, "The purpose of observation status is to determine the need for further treatment or for inpatient admission... Observation status is commonly assigned to patients who present to the ED and who then require a period of treatment or monitoring before a decision is made concerning their admission or discharge... An inpatient is defined as a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services... [name of hospital] has 37 formal observation beds distributed throughout the hospital. None are located in the ED."

4. Review of an ED admission dated 9/18/10 revealed 20 year old Pt #21 arrived by air transport following a Motor Vehicular Crash (MVC). After examination in the ED Pt #21 was admitted as an inpatient and surgery was performed on 9/18/10.

The Operative Report dated 9/18/10 documented the Preoperative Diagnoses included: 1. Comminuted right talus fracture, 2. Comminuted right calcaneus fracture dislocation, and 3. Vascular compromise distal forefoot. The Postoperative Diagnoses were the same as the Preoperative except 3. documented, "vascular compromise distal forefoot which returned to normal upon reduction." The Operative Report documented the following procedures were performed: Open reduction and external fixation of right talus fracture, Closed reduction of right calcaneus fracture and application of a short leg splint. Under "Finding" on the Operative Report it was documented Pt #21 had white toes and a sluggish capillary refill prior to reduction and subsequently had brisk capillary refill at the end of the procedure. Documentation under "Procedure" read... "He had a palpable posterior tibial pulse prior to splinting as well as a dopplerable anterior tib [tibia]. He had brisk capillary refill and his toes were pink."

The Discharge Summary dated 09/22/10 documented, "...The hospital course was largely unremarkable as the patient convalesced appropriately from the procedure/injury." Upon discharge, Pt #21 was provided instruction to avoid weight bearing on the right leg/foot, keep it elevated most of the day, not remove his splint or dressings, and to call the nurse (telephone number provided) for a temperature over 101.5 or for numbness or tingling in his arms or legs.

5. Review of a second ED admission dated 9/28/10 revealed Patient #21 returned to the ED 6 days after being discharged from his inpatient stay. An Admission Facesheet documented the patient was unemployed and had "NO INSURANCE."

The "Emergency Department Nurse Triage" documented Pt #21 arrived at 18:12 with, "Chief complaint: infection of skin... Pt complains of pain and blister to top of left [right] foot. Surgery on 9/18 s/p [status post] MVC [Motor Vehicle Crash]. Discharged Wednesday by Ortho [Orthopedics]. Fever 102.6 at home. Vital Signs ...P [Pulse]: 141 T [Temperature]: 100.2 F [Fahrenheit] ...Pain: 8/10... Triage assessment Nurse objective: strong odor noted from affected foot, ace wrap with fixator in place, large purple blister noted to foot..." Current medications were listed as aspirin, a laxative, gabapentin, Morphine and Oxycodone with acetaminophen.

In an "ED Attending History and Physical (H&P)" dictated 9/29/10 at 00:36, ED Physician #1 documented Pt #21, "...notes that he has had fever at home of 102.6. He noticed his heart rate has been fast. He has had increase of blisters ...and he has had discoloration of his toes... No obvious drainage but he has had a foul smell from underneath the cast on the right side... Physical Examination:... he is tachycardic at 141... temperature is 100.2... right lower extremities was in a splint and had discolored right great toe, third toe and fourth toe with a bullae [large blister] over the dorsum of the foot that extend underneath the dressings... Laboratories demonstrated a white cell count 12.4... sedimentation rate was 132... Patient is a 20-year-old male with history of fevers who presents to the emergency department with increase drainage and bullae. He has leukocytosis and elevated sedimentation rate. Orthopedics was consulted. Plans for admission to the hospital ..." The ED Attending H&P documented ED diagnoses: "1. Bullae of the foot related to fractures. 2. External fixator. 3. Acute febrile illness. 4. Elevated sedimentation rate."

A Complete Blood Count (CBC) with Differential and BMP was collected on 9/28/10 at 19:15 and revealed a White Blood Cell value of 12.4, the Sedimentation Rate was elevated at 132. Blood Cultures were performed at 19:20 and 19:25. The negative blood cultures results was available on 10/4/10, several days after the patient had been discharged. No culture of the right foot was performed. The CBC with Differential and BMP were repeated 9/29/10 at 05:24 and the WBC had increased to 14.1.

Radiology reports revealed Doppler studies of the lower extremities were documented 9/29/10 at 8:30 AM. Impression documented, "No evidence of lower extremity deep venous thrombosis . Unable to evaluate the right calf due the presence of casting material." There was no evidence in the medical record to indicate the test was repeated with the splint removed. Chest X-rays on 9/29/10 at 9:13 AM documented, "Impression: Negative chest radiographs."

A H&P dictated at 03:57 on 9/29/10 by Orthopaedic Resident Physician #1 documented Pt #21's "CHIEF COMPLAINT: Fever and blisters on right foot. HISTORY OF PRESENT ILLNESS: ...underwent external fixation of right talar neck fracture and comminuted right calcaneal fracture 9/18/10 ...The patient had a significant swelling at the time of injury and has some ecchymoses on his right foot postoperatively, but was able to move his toes and had good pulses. He had blue toes at the time of discharge ... he did develop fevers to 103 as well as blister on the dorsum of his foot near the toes that was worrisome, so he came to the emergency department tonight ... PHYSICAL EXAMINATION: Temperature 103.4 Fahrenheit, heart rate 100... His splint was removed which revealed diffuse blistering and ecchymoses of his right foot especially on the medial aspect of the foot distal to the medial malleolus tracking posteriorly as well as posterolateral as well. There is a new blister formed on the dorsum of his foot just proximal to the MTP [metatarsophalangeal] joints of digits 3 through 5. He also has some dark blue/purple almost black discoloration of the great toe and lateral two toes as well ... He has 2+ [plus] palpable dorsalis pedis pulse and his toes are warm... His external fixator is in place with no obvious pus draining from the pin sites. There is a diffuse erythema about the right foot, but not tracking proximal to the ankle joint ... Given the patient's persistent fever even here while in the hospital, I will plan to admit him to the hospital for evaluation and treatment under the Orthopaedic Trauma service. We will hold on antibiotics for now since his vital signs are stable and he does not appear septic... for possible irrigation and debridement tomorrow pending discussion with the staff in the morning ... The patient's wounds are re-dressed..."
The H&P did not document a diagnosis of the patient's illness.

An ED Order Summary for this visit documented physician's orders:
a) On 9/28/10 at 10:04 Normal Saline bolus 1000 milliliters (ml) intravenously (IV).
19:53 Morphine injection 6 milligrams (mg) IV stat and Ibuprofen 600 mg by mouth (PO) stat,
22:07 Morphine injection 6 mg IV stat.
b) On 9/29/10, 01:19 "place in observation"
01:21 "notify house officer: T [Temperature] > [greater than] 101.4 HR [Heart Rate] > 120..."
01:21 "registry: seen by ortho [orthopedics] trauma ...s/p [status post] ex fix r talus/calc [calcaneus] on 9/18. back with fever, drainage, and black toes. palpable pulses. plan: admit to obs [observation], poss [possible] abx [antibiotics] vs [versus] i&d [incise and drain], d/w [discuss with] (named physician) in am."
01:21 Volurex incentive spirometer q (every) 2 h (hours)
01:21 Nursing: clean pins with a mixture of one-half strength normal saline and 1/2 peroxide three times daily
01:23 Diphendydramine 25 mg PO q 6 h
01:23 Percocet 10 mg/ 325 mg 1 tab q 4 h
01:25 Hydromorphone 1 mg IV stat,
01:25 Acetaminophen 650 mg PO stat,
02:00 D5 (Dextrose 5%) 1/2 NS: 75 ml/hr (hour) IV infusion
05:21 Neurovascular checks q 4 h
06:00 Vital signs q 8 h
06:00 Intake and output q 6 h record
06:00 In and out cath (catheter) q 6 h for inability to void every 6 hours
06:00 Morphine SR (sustained release) 30 mg PO q 8 h
10:00 Enoxaparin for DVT prophylaxis 40 mg subcut (subcutaneous) q day
10:00 Senna/Docusate 2 tab po BID (twice a day)
10:28 "discharge to home."
(There was no documentation in the medical record to evidence the pins had been cleaned. The medical record did not contain any documentation to explain why the patient was to be discharged or a discharge diagnosis.)

Nursing assessments and flowsheets for 9/28/10 and 9/29/10 documented:
9/28/10, "18:38 (Pulse) 141 (Temperature) 100.2..."
18:55, "Pt to ER [Emergency Room] with increase rt [right] foot pain and blisters..."
20:02, "(Pulse) 131, (Temperature) 103.3..."
22:07, "(Pulse) 125, (Temperature) 103.4..."
22:15, "pt medicated for pain..."
22:21, "Pt back from xray [radiology] with cont [continued] fever and increase in rt foot pain..."
23:15, " ...awaiting Ortho [Orthopedics] MD [Medical Doctor] to evaluate ...R [right] foot has blisters dark purple to black..."
9/29/10, "00:35 ...MD ... at bedside..."
01:42, "Pt awaiting Ortho MD consult. Pt given RX [prescribed medication] for pain. And rx po for fever. Pain 8/10..."
02:15, "Ortho MD consult at bedside... "
02:42, "ortho resplinted R foot..."
0345, " pt asking why he wasn't receiving ABX [antibiotics]... "
04:05, "pt informed that plan was to wash out and culture R foot before abx were administered in order to get the best results..."
04:50, "pt requesting a hospital bed..."
06:00, "Pt to C21 [an area within the ED]. Placed on hospital bed... Black, purple discoloration noted to toes of right foot. Blood blister noted to top of right foot. Pt reports numbness to right foot... Rates pain 7/10 at this time. IVF [IV fluids] initiated ...Morphine SR administered ..."
07:38, " ...Awaiting transport to OR [Operating Room] for surgery..."
07:54, "MD at bedside..."
12:28, "ortho at BS [bedside] for splint placement..."
13:03, " ...Pt. given IV pain medication. Family at bedside. Pt asks to see attending MD. Team paged..."
14:48, "Pt's family asks to speak to MD again. Page sent again. Pt;s repeat temperature taken and found to be 103.5. Team paged..."
14:59, "MD at bedside..."
15:17, "Pt informed of plan for d/c [discharge]. Pt told that elevated temperature is not an issue for delaying d/c. Pt's most recent temp 103.5 as documented. MD informed..."
15:20, "Pt's IV removed in preparation for discharge... CN [Charge Nurse] informed of plan for discharge despite elevated temp. Pt informed by D/c MD that he needs to see his PCP. Will continue to monitor until d/c..."
15:21, "Pt given discharge teaching related to his diagnosed codnition of crush injury. Pt informed to monitor fever closely. Pt given copies of all after crae instructions. Pt denies further needs, but expresses concern about elevated temp. Family at bedside."
(There was no documentation to explain the reason Pt. #21 and/or the patient's family requested to see the physician at 13:03 or 14:48. There was no documentation of the physician's communication with the patient and family at 12:28 or 14:59.)

During an interview on 7/18/12 at 09:50, in Room 4230 at Medical Center East, Orthopedic Trauma Surgeon #1 stated he had seen Pt. #21 during his initial hospitalization, heard the patient was in the ED on 9/29/10, went to the ED from surgery and saw the patient. He stated he reviewed the labs, x-rays, and the patient's record and determined there were no obvious signs of infection or necrosis of the foot. He stated the foot was viable.
There was no documentation in the medical record this physician visited, examined and/or treated Pt #21 on 9/28/10 or 9/29/10.

Medical record review revealed the patient remained in the ED throughout this stay. There was no documentation of further plans to admit, treat with antibiotics, perform and I&D or not to provide these treatments was discussed with the patient. Following the H&P dictated at 03:57, there was no physician documentation of the patient's condition, plan of care, diagnosis or prognosis. There was no documentation to explain why Pt #21 remained in the ED from 10:28 when the discharge order was given until 4 hours and 53 minutes later when he received discharge instructions.

4. Medical record review revealed Patient #21 returned once more to the ED on 10/3/10. The History and Physical documented Patient #21 presented to the ED with the Chief Complaint of Maggots in his ankle dressing. The physician documented Patient #21 had been seen at the facility several days prior for concern for infection. At home his fever had been 103 and he had had increased purulent drainage from the pin sites. He had had pain and his great toe had continued to be black. The Musculoskeletal examination documented the right lower extremity showed necrosis of the right great toe and was very foul-smelling. When the dressing was removed, there were a large number of maggots seen near the pin site. The ED diagnosis was listed as Gangrenous right lower extremity post complex foot fracture repair. Orthopedics was consulted.

Review of the Operative Report dated 10/04/10 revealed the following under the History: Patient #21 had been discharged from the facility on 9/23/10 following external fixation which restored the vascular flow to his foot. He had returned to the ED on 9/29/10 for fever and darkening of his toes. He had been evaluated and sent home. When he presented to the ED on 10/3/10, the physician documented it was apparent he had dry gangrene of his great toe and he had drainage from his foot. Upon entering the room of Patient #21 the physician documented he could smell a horrendous odor and on evaluating his foot, the physician documented it was not a salvageable situation. "...His great toe, third, fourth and fifth toes were necrotic. The entire plantar surface of his foot was dead. His skin was sloughing from his entire foot. He had copious purulent material draining from his foot ...We had a thorough discussion of this is a situation where he could get very sick, meaning bacteremia and sepsis, and potentially die ...my plan was to take him to the operating room for a guillotine amputation and start antibiotics to cover for necrotizing fascitis as this is obviously in our differential given the severity of the infection." The Operative Report Procedure documented the external fixator pin sites were removed. The right foot was cold and completely nonviable. "It was so foul smelling that everyone in the operating room had to use peppermint spray on their mask. I was really taken aback by the severity of the infection ...I began by draining some of the pus into a cup and sending this for immediate culture ...We then gave vancomycin and Zosyn for broad coverage. I then performed the guillotine amputation above the lateral malleoli which was several inches above the erythema."

Regarding Pt #21's visit on 9/28/10, the cause for the elevated temperature, tachycardia, elevated WBC, blistering of the right foot and pain were not documented in the medical record and Pt. #21 received no treatment other than medication for pain and Intravenous fluids. He was discharged home on 9/29/10 with instructions for "Activity: Non Weight Bearing: Right Leg" and to continue his medications. There were no instructions for care and/or complications to monitor for the patient's right foot.

6. As a comparison, the following 5 sampled patients also presented to the ED with chief complaint of elevated temperatures:

Pt #19 presented to the ED 9/16/10 with complaint of infection of skin. The triage documented the pt had a left foot amputation in 2009, and has had an infection at the site for "past couple months". The triage completed at 10:51 documented the patient's temperature was 100.3F. The patient was treated with Vancomycin and Clindamycin IV. The patient was taken to surgery, the wound was drained and fluids cultured, and the patient was admitted to the hospital for further care. Pt #19 had Medicaid.

Pt #14 presented to the ED 8/1/10 with complaint of abscess in folds of buttocks. The triage form completed at 11:38 AM documented the patient's temperature was 101.3F. The patient was taken to surgery for I&D of the left gluteal abscess with general anesthesia. The patient was treated with Clindamycin IV and discharged home 8/1/10 with prescriptions for Clindamycin and Lortab for pain. Pt #14 had no insurance.

Pt #8 presented to the ED 6/15/12 with complaint of fever. The triage form completed at 00:57 documented, "...pt dc [discharged] from hospital Monday following most recent surgery... for muscle/skin graft; pt reports fever worse... w/tmax 103.1... receiving rocephin IV q 24h for a 'strep' bacteria..." The patient was admitted to the hospital. Pt #8 had TennCare Insurance.

Pt #2 presented to the ED 4/1/12 with complaint of fever since waking up this morning. He reported he had chemotherapy and received 2 units of blood within the past week and was told to come have his white count checked. Pt #2 was assessed with a temperature of 100.7 during triage at 10:26. Pt #2 was treated with antibiotics Cefepime 2000 mg IV and Vancomycin 1000 mg IV, and with pain medication. He was admitted as an oncology in-patient. Pt #2 had private insurance.

Pt #1 presented to the ED 4/1/12 with complaint of fever for 2 days. A temperature of 103.6F was assessed during triage at 04:54. The patient was treated with Ibuprofen 600 mg and Azithromycin 500 mg in the ED. Pt #1 was discharged home at 08:00 with antibiotics prescribed. Pt #1 had private insurance.

Based on document review, medical record review and interview, it was determined the hospital failed to provide stabilizing treatment prior to discharging 1 of 25 (Patient #21) sampled patient's who came to the Emergency Department (ED) seeking emergency care and services. Failure to ensure determine the cause of the patient's illness led to the patient being released without having received treatment and stabilization on the 9/28/10 visit.

The findings included:

1. Review of the hospital's policy, "Adult Emergency Dept [Department] Emergency Screening, Stabilization and Transfer ..." revealed, "...Purpose: To establish procedures for the medical screening of patients presenting to the ED to determine whether an emergency medical condition exists... Stabilization of ED patients... the physician will initiate necessary stabilizing treatment and diagnostic testing... providing medical treatment within the capabilities of the hospital's Emergency Department... necessary to determine that no material deterioration of the patient's condition is likely to result."

2. Review of the hospital's policy, "Standards of Care" revealed, "Purpose: To define minimal standards of care for each patient who presents to the Emergency Department (ED) for treatment... The attending physician is accountable for all medical care rendered in the department... The plan of care will be collaborative effort between physicians and Emergency Department nursing staff and will be documented in the medical record."

3. Review of a written document submitted by the facility on 7/19/12 at 4:03 PM in answer to questions concerning Observation orders for Pt #21 revealed, "The purpose of observation status is to determine the need for further treatment or for inpatient admission... Observation status is commonly assigned to patients who present to the ED and who then require a period of treatment or monitoring before a decision is made concerning their admission or discharge... An inpatient is defined as a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services... [name of hospital] has 37 formal observation beds distributed throughout the hospital. None are located in the ED."

4. Review of an ED admission dated 9/18/10 revealed 20 year old Pt #21 arrived by air transport following a Motor Vehicular Crash (MVC). After examination in the ED Pt #21 was admitted as an inpatient and surgery was performed on 9/18/10. The procedure performed included Open reduction and external fixation of right talus fracture, Closed reduction of right calcaneus fracture and application of a short leg splint. The Preoperative Diagnoses included: Comminuted right talus fracture, Comminuted right calcaneus fracture dislocation, and Vascular compromise distal forefoot. The Postoperative Diagnoses were the same except "vascular compromise distal forefoot which returned to normal upon reduction" was added. The Operative Report documented the following procedures were performed: Under "Finding" on the Operative Report it was documented Pt #21 had white toes and a sluggish capillary refill prior to reduction and subsequently had brisk capillary refill at the end of the procedure. Documentation under "Procedure" read... "He had a palpable posterior tibial pulse prior to splinting as well as a dopplerable anterior tib [tibia]. He had brisk capillary refill and his toes were pink."

The Discharge Summary dated 09/22/10 documented, "...The hospital course was largely unremarkable as the patient convalesced appropriately from the procedure/injury." Upon discharge, Pt #21 was provided instruction to avoid weight bearing on the right leg/foot, keep it elevated most of the day, not remove his splint or dressings, and to call the nurse (telephone number provided) for a temperature over 101.5 or for numbness or tingling in his arms or legs.

5. Review of a second ED admission dated 9/28/10 revealed Patient #21 returned to the ED 6 days after being discharged from his inpatient stay. An Admission Facesheet documented the patient was unemployed and had "NO INSURANCE."

The "Emergency Department Nurse Triage" documented Pt #21 arrived at 18:12 with, "Chief complaint: infection of skin... Pt complains of pain and blister to top of left [right] foot. Surgery on 9/18 s/p [status post] MVC [Motor Vehicle Crash]. Discharged Wednesday by Ortho [Orthopedics]. Fever 102.6 at home. Vital Signs ...P [Pulse]: 141 T [Temperature]: 100.2 F [Fahrenheit] ...Pain: 8/10... Triage assessment Nurse objective: strong odor noted from affected foot, ace wrap with fixator in place, large purple blister noted to foot..." Current medications were listed as aspirin, a laxative, gabapentin, Morphine and Oxycodone with acetaminiphen.

In an "ED Attending History and Physical (H&P)" dictated 9/29/10 at 00:36, ED Physician #1 documented Pt #21, "...notes that he has had fever at home of 102.6. He noticed his heart rate has been fast. He has had increase of blisters ...and he has had discoloration of his toes... No obvious drainage but he has had a foul smell from underneath the cast on the right side... Physical Examination:... he is tachycardic at 141... temperature is 100.2... right lower extremities was in a splint and had discolored right great toe, third toe and fourth toe with a bullae [large blister] over the dorsum of the foot that extend underneath the dressings... Laboratories demonstrated a white cell count 12.4... sedimentation rate was 132... Patient is a 20-year-old male with history of fevers who presents to the emergency department with increase drainage and bullae. He has leukocytosis and elevated sedimentation rate. Orthopedics was consulted. Plans for admission to the hospital ..." The ED Attending H&P documented ED diagnoses: "1. Bullae of the foot related to fractures. 2. External fixator. 3. Acute febrile illness. 4. Elevated sedimentation rate."

A Complete Blood Count (CBC) with Differential and BMP was collected on 9/28/10 at 19:15 and revealed a White Blood Cell value of 12.4, the Sedimentation Rate was elevated at 132. Blood Cultures were performed at 19:20 and 19:25. The negative blood cultures results was available on 10/4/10, several days after the patient had been discharged. No culture of the right foot was performed. The CBC with Differential and BMP were repeated 9/29/10 at 05:24 and the WBC had increased to 14.1.

A H&P dictated at 03:57 on 9/29/10 by Orthopaedic Resident Physician #1 documented Pt #21's "CHIEF COMPLAINT: Fever and blisters on right foot... he did develop fevers to 103 as well as blister on the dorsum of his foot near the toes that was worrisome, so he came to the emergency department tonight ... PHYSICAL EXAMINATION: Temperature 103.4 Fahrenheit, heart rate 100... His splint was removed which revealed diffuse blistering and ecchymoses of his right foot... There is a new blister formed on the dorsum of his foot... He also has some dark blue/purple almost black discoloration of the great toe and lateral two toes as well ... He has 2+ [plus] palpable dorsalis pedis pulse and his toes are warm... His external fixator is in place with no obvious pus draining from the pin sites. There is a diffuse erythema about the right foot, but not tracking proximal to the ankle joint ... Given the patient's persistent fever even here while in the hospital, I will plan to admit him to the hospital for evaluation and treatment under the Orthopaedic Trauma service. We will hold on antibiotics for now since his vital signs are stable and he does not appear septic... for possible irrigation and debridement tomorrow pending discussion with the staff in the morning ... The patient's wounds are re-dressed..."
The H&P did not document a diagnosis of the patient's illness.

An ED Order Summary for this visit documented physician's orders:
a) On 9/28/10 at 10:04 Normal Saline bolus 1000 millileters (ml) intravenously (IV).
19:53 Morphine injection 6 milligrams (mg) IV stat and Ibuprofen 600 mg by mouth (PO) stat,
22:07 Morphine injection 6 mg IV stat.
b) On 9/29/10, 01:19 "place in observation"
01:21 "notify house officer: T [Temperature] > [greater than] 101.4 HR [Heart Rate] > 120..."
01:21 "registry: seen by ortho [orthopedics] trauma ...s/p [status post] ex fix r talus/calc [calcaneus] on 9/18. back with fever, drainage, and black toes. palpable pulses. plan: admit to obs [observation], poss [possible] abx [antibiotics] vs [versus] i&d [incise and drain], d/w [discuss with] (named physician) in am."
01:21 Volurex incentive spirometer q (every) 2 h (hours)
01:21 Nursing: clean pins with a mixture of one-half strength normal saline and 1/2 peroxide three times daily
01:23 Diphendydramine 25 mg PO q 6 h
01:23 Percocet 10 mg/ 325 mg 1 tab q 4 h
01:25 Hydromorphone 1 mg IV stat,
01:25 Acetaminophen 650 mg PO stat,
02:00 D5 (Dextrose 5%) 1/2 NS: 75 ml/hr (hour) IV infusion
05:21 Neurovascular checks q 4 h
06:00 Vital signs q 8 h
06:00 Intake and output q 6 h record
06:00 In and out cath (catheter) q 6 h for inability to void every 6 hours
06:00 Morphine SR (sustained release) 30 mg PO q 8 h
10:00 Enoxaparin for DVT prophylaxis 40 mg subcut (subcutaneous) q day
10:00 Senna/Docusate 2 tab po BID (twice a day)
10:28 "discharge to home."
(There was no documentation in the medical record to evidence the pins had been cleaned. The medical record did not contain any documentation to explain why the patient was to be discharged without receiving treatment other than IV fluids and pain medication, why he was being discharged with an elevated temperature, tachycardia, and pain or a discharge diagnosis.)

Nursing assessments and flowsheets for 9/28/10 and 9/29/10 documented:
9/28/10, "18:38 (Pulse) 141 (Temperature) 100.2..."
18:55, "Pt to ER [Emergency Room] with increase rt [right] foot pain and blisters..."
20:02, "(Pulse) 131, (Temperature) 103.3..."
22:07, "(Pulse) 125, (Temperature) 103.4..."
22:15, "pt medicated for pain..."
22:21, "Pt back from xray [radiology] with cont [continued] fever and increase in rt foot pain..."
23:15, " ...awaiting Ortho [Orthopedics] MD [Medical Doctor] to evaluate ...R [right] foot has blisters dark purple to black..."
9/29/10, "00:35 ...MD ... at bedside..."
01:42, "Pt awaiting Ortho MD consult. Pt given RX [prescribed medication] for pain. And rx po for fever. Pain 8/10..."
02:15, "Ortho MD consult at bedside... "
02:42, "ortho resplinted R foot..."
0345, " pt asking why he wasn't receiving ABX [antibiotics]... "
04:05, "pt informed that plan was to wash out and culture R foot before abx were administered in order to get the best results..."
04:50, "pt requesting a hospital bed..."
06:00, "Pt to C21 [an area within the ED]. Placed on hospital bed... Black, purple discoloration noted to toes of right foot. Blood blister noted to top of right foot. Pt reports numbness to right foot... Rates pain 7/10 at this time. IVF [IV fluids] initiated ...Morphine SR administered ..."
07:38, " ...Awaiting transport to OR [Operating Room] for surgery..."
07:54, "MD at bedside..."
12:28, "ortho at BS [bedside] for splint placement..."
13:03, " ...Pt. given IV pain medication. Family at bedside. Pt asks to see attending MD. Team paged..."
14:48, " Pt's family asks to speak to MD again. Page sent again. Pt;s repeat temperature taken and found to be 103.5. Team paged..."
14:59, "MD at bedside..."
15:17, "Pt informed of plan for d/c [discharge]. Pt told that elevated temperature is not an issue for delaying d/c. Pt's most recent temp 103.5 as documented. MD informed..."
15:20, "Pt's IV removed in preparation for discharge... CN [Charge Nurse] informed of plan for discharge despite elevated temp. Pt informed by D/c MD that he needs to see his PCP. Will continue to monitor until d/c..."
15:21, "Pt given discharge teaching related to his diagnosed codnition of crush injury. Pt informed to monitor fever closely. Pt given copies of all after crae instructions. Pt denies further needs, but expresses concern about elevated temp. Family at bedside."
(There was no documentation to explain the reason Pt. #21 and/or the patient's family requested to see the physician at 13:03 or 14:48. There was no documentation of the physician's communication with the patient and family at 12:28 or 14:59.)

During an interview on 7/18/12 at 09:50, in Room 4230 at Medical Center East, Orthopedic Trauma Surgeon #1 stated he had seen Pt. #21 during his initial hospitalization, heard the patient was in the ED on 9/29/10, went to the ED from surgery and saw the patient. He stated he reviewed the labs, x-rays, and the patient's record and determined there were no obvious signs of infection or necrosis of the foot. He stated the foot was viable.
There was no documentation in the medical record this physician visited, examined and/or treated Pt #21 on 9/28/10 or 9/29/10.

Medical record review revealed the patient remained in the ED throughout this stay. There was no documentation of further plans to admit, treat with antibiotics, perform and I&D or not to provide these treatments was discussed with the patient. Following the H&P dictated at 03:57, there was no physician documentation of the patient's condition, plan of care, diagnosis or prognosis. There was no documentation to explain why Pt #21 remained in the ED from 10:28 when the discharge order was given until 4 hours and 53 minutes later when he received discharge instructions.

4. Medical record review revealed Patient #21 returned once more to the ED on 10/3/10. The History and Physical documented Patient #21 presented to the ED with the Chief Complaint of Maggots in his ankle dressing. The physician documented Patient #21 had been seen at the facility several days prior for concern for infection. At home his fever had been 103 and he had had increased purulent drainage from the pin sites. He had had pain and his great toe had continued to be black. The Musculoskeletal examination documented the right lower extremity showed necrosis of the right great toe and was very foul-smelling. When the dressing was removed, there were a large number of maggots seen near the pin site. The ED diagnosis was listed as Gangrenous right lower extremity post complex foot fracture repair. Orthopedics was consulted. The Operative Report dated 10/04/10 documented, "...His great toe, third, fourth and fifth toes were necrotic. The entire plantar surface of his foot was dead. His skin was sloughing from his entire foot. He had copious purulent material draining from his foot ... We then gave vancomycin and Zosyn for broad coverage. I then performed the guillotine amputation above the lateral malleoli which was several inches above the erythema."

6. As a comparison, the following 5 sampled patients also presented to the ED with chief complaint of elevated temperatures:

Pt #19 presented to the ED 9/16/10 with complaint of infection of skin. The triage documented the pt had a left foot amputation in 2009, and has had an infection at the site for "past couple months". The triage completed at 10:51 documented the patient's temperature was 100.3F. The patient was treated with Vancomycin and Clindamycin IV. The patient was taken to surgery, the wound was drained and fluids cultured, and the patient was admitted to the hospital for further care. Pt #19 had Medicaid.

Pt #14 presented to the ED 8/1/10 with complaint of abscess in folds of buttocks. The triage form completed at 11:38 AM documented the patient's temperature was 101.3F. The patient was taken to surgery for I&D of the left gluteal abscess with general anesthesia. The patient was treated with Clindamycin IV and discharged home 8/1/10 with prescriptions for Clindamycin and Lortab for pain. Pt #14 had no insurance.

Pt #8 presented to the ED 6/15/12 with complaint of fever. The triage form completed at 00:57 documented, "...pt dc [discharged] from hospital Monday following most recent surgery... for muscle/skin graft; pt reports fever worse... w/tmax 103.1... receiving rocephin IV q 24h for a 'strep' bacteria..." The patient was admitted to the hospital. Pt #8 had TennCare Insurance.

Pt #2 presented to the ED 4/1/12 with complaint of fever since waking up this morning. He reported he had chemotherapy and received 2 units of blood within the past week and was told to come have his white count checked. Pt #2 was assessed with a temperature of 100.7 during triage at 10:26. Pt #2 was treated with antibiotics Cefepime 2000 mg IV and Vancomycin 1000 mg IV, and with pain medication. He was admitted as an oncology in-patient. Pt #2 had private insurance.

Pt #1 presented to the ED 4/1/12 with complaint of fever for 2 days. A temperature of 103.6F was assessed during triage at 04:54. The patient was treated with Ibuprofen 600 mg and Azithromycin 500 mg in the ED. Pt #1 was discharged home at 08:00 with antibiotics prescribed. Pt #1 had private insurance.


Regarding Pt #21's visit on 9/28/10, the cause for the elevated temperature, tachycardia, elevated WBC, blistering of the right foot and pain were not documented in the medical record and Pt. #21 received no treatment other than medication for pain and Intravenous fluids. He was discharged home on 9/29/10.