HospitalInspections.org

Based on interview and record review, the facility failed to implement their "Abnormal Findings - Recall for Follow up," policy and procedure (P&P), when Patient 16 was not notified of a left forearm fracture after discharge from the Emergency Department (ED).

This failure resulted in a second visit to the ED with a delay in treatment.

Findings:

On December 23, 2024, an unannounced visit was conducted at the facility to investigate a complaint.

On December 23, 2024, at 2:05 p.m., a review of Patient 16's medical record was conducted with the Regulatory Specialist (RS). A facility document titled, "ED Provider MSE [Medical Screening Exam] Note" dated September 14, 2024, indicated Patient 16 arrived to the ED on September 6, 2024, at 6:59 p.m. with a chief complaint of arm injury left forearm resulting from a fall. Further review of the medical record indicated, an XRAY(XR) of the left forearm was completed on September 14, 2024, at 7:39 p.m.

Review of a facility document titled, "ED Provider Notes," dated September 14, 2024, was reviewed and indicated, "...Relayed imaging to patient...Did discuss the potential for an occult fracture but otherwise doubt dislocation...Will call patient at time of radiology read if any new changes...DISPOSITION: Discharge with continued outpatient follow up..."

Review of the facility document titled, "XR [XRAY] Forearm - Lt [left]" dated September 15, 2024, indicated, "...Findings: Mildly comminuted fracture of the radial head..."

Review of the facility document titled, "ED Provider Notes," dated September 19, 2024, was reviewed and indicated, "...Received a call from patient's mother that patient was having a lot of pain. X ray was read...Review of chart does not correlate with radiology read. Called patient and advised her to return to ED for further evaluation..."

Review of the facility document titled, "ED Provider Notes,"dated September 19, 2024, was reviewed and indicated, "...Presents to [Name of facility] ED with concern for LUE [left upper extremity] fracture follow up...Patient was told on 9/14 [September 14] that if there was a fracture she would be notified but was never actually informed she had a fracture. Patient was discharged with a sling...ED Course Procedure: Strapping Application (Lt [left] posterior elbow splint)..."

On December 24, 2024, at 10:15 a.m., an interview was conducted with Radiologist 1. Radiologist 1 stated the facility does not have a Radiologist during the night to read Xray films and the Contract Agency is used from the hours of 4 p.m., to 7a.m. For all ED studies we request the Contract Agency to read it by 10 a.m. the next morning. The after hours results go back to the ordering provider but sometimes the ED provider gets the films first. Radiologist 1 stated the results go back to the ordering Provider and the Provider gives the patient the Xray results.

On December 24, 2024, at 10:35 a.m., an interview was conducted with Provider 1. Provider 1 stated she will read the Xray result and inform the patient right away while inpatient and let every patient know if they don't receive a call from the provider they can reach out to us or check My Chart for the result. Provider 1 stated Patient 16 should have received a call with the abnormal result and she may have forgot to call.

Review of the facility P&P titled "Abnormal Findings - Recall for Follow up," dated July 10, 2024, indicated, "...The Patient Recall process will be used when: Abnormal labs, radiology studies, diagnostic studies, or electrocardiogram are reviewed by the ED provider and the patient has already been discharged from the ED...If change in patient management or follow-up is indicated, every effort will be made to contact the patient, preferably by phone call..."