HospitalInspections.org

Based on a review of medical record (MR) and interview with staff (EMP), it was determined that the facility failed to provide good quality care and high professional standards by failing to provide an orthopedic reevaluation for one of ten medical record reviewed (MR1).

Findings include:

A review on August 2, 2011, of the physician consult report on MR1, dated July 15, 2011, revealed, "It is unclear why the patient was discharged without having been fully evaluated with Orthopedic Surgery. They were under the impression that the patient was not going to be discharged and they had planned to reevaluate in the morning ... "

A review on August 2, 2011, of MR1 revealed the patient had an orthopedic evaluation on the evening of July 14, 2011, at 11:50 PM. There was no orthopedic reevaluation documented. The patient was then discharged around 3:00 AM on July 15, 2011. The patient was then admitted the same day around 3:53 PM and taken to the operating room for irrigation and debridement of right heel wound.

An interview conducted on August 8, 2011, at 9:45 AM with EMP5 confirmed that EMP5 was "under the impression" that the patient was to have been admitted on the first emergency department visit.