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Based on record review and interview, the hospital failed to ensure compliance with §489.24 (d) (1-3) Stabilizing Treatment as evidenced by:

Failing to provide stabilizing treatment within its capability and capacity for a medical emergency as evidenced by a patient presenting to the Emergency Department (ED) with a dislocated shoulder being discharged home without reducing the dislocation for 1 (#2) of 20 (#1-#20) patients sampled for emergency medical conditions. This deficient practice resulted in the patient presenting to another ED immediately after discharge in pain where her dislocated shoulder was reduced by the ED physician.

Based on record review and interview, the hospital failed to provide stabilizing treatment within its capability and capacity for a medical emergency as evidenced by a patient presenting to the Emergency Department (ED) with a dislocated shoulder being discharged home without reducing the dislocation for 1 (#2) of 20 (#1-#20) patients sampled for emergency medical conditions. This deficient practice resulted in the patient presenting to another ED immediately after discharge in pain where her dislocated shoulder was reduced by the ED physician.

Findings:

Review of the ED record dated 6/2/15 at 7:58 p.m. for Patient #2 revealed she arrived at the ED with the chief complaint of syncope (loss of consciousness). The history of present illness listed an acute injury to the right shoulder with moderate severity. Further review revealed Patient #2's sister said she had a syncopal episode and had fallen on her right shoulder. Review of the physical exam revealed she had right shoulder pain and was unable to abduct (lateral movement away from the body) her shoulder.

Review of the ED record for Patient #2 revealed an order for 3 views of the right shoulder on 6/2/15 at 8:50 p.m. that was completed on 6/2/15 at 9:56 p.m. The x-rays were interpreted by S3MD on 6/2/15 at 9:56 p.m. as an anterior dislocation of the right shoulder.

Review of the triage vital signs dated 6/2/15 at 8:11 p.m. revealed Patient #2 had an assessed pain score of 10/10 by S4RN. No other pain scales were documented during the ED visit.

Review of the medication record for Patient #2 revealed she had been given Tylenol 1000 mg on 6/2/15 at 10:37 p.m. for pain. Her response to the treatment was documented as "unchanged" at 10:54 p.m.

Review of the nursing discharge instructions and patient disposition revealed Patient #2 was discharged to home on 6/2/15 at 10:53 p.m. Review of the ED Department Discharge Instructions for Patient #2 revealed in part:
You have been seen for a dislocation of your right shoulder.
The dislocation has not been reduced (repaired). The doctor wants you to see an orthopedist as soon as possible. Keep your arm in the sling at all times till seen by an orthopedist.
A dislocation is when one of the bones that make up a joint gets out of place. It is no longer in the right place to let the joint bend. Sometimes a ligament or set of ligaments is injured during the dislocation. Shoulder dislocations can also injure one of the nerves which give the arm and hand sensation (feeling). There may also be a fracture (broken bone) with a dislocation.

Further review revealed discharge instructions relative to seizure activity with instructions to follow up with a specialist.

Review of the ED medical record for Patient #2 from Hospital "A" revealed she was admitted on 6/2/15 at 11:27 p.m. and discharged on 6/3/15 at 2:35 a.m. The reason for the visit was listed as "pain in the right shoulder" and the diagnosis was "closed dislocation of shoulder." The procedure performed was listed as closed treatment of shoulder dislocation. The pain scales assessed at the hospital were documented as a 10 (out of 10) on 6/2/15 at 11:31 p.m. and a 10 on 6/3/15 at 12:37 a.m. Further review revealed a note by a registered nurse in the ED that read: Pt (Patient #2) just seen in Prevost ER for dislocated right shoulder. Pt's family states, "Doctor there did not feel confident he could reduce the shoulder." Pt treated there and a sling applied.

In an interview on 7/13/15 at 1:50 p.m. with S4RN, she said she triaged Patient #2 who came in to the ED with her sister. S4RN said Patient #2's sister reported that Patient #2 had passed out and fell on her right shoulder. S4RN said a pain scale assessment was done in triage and indicated that Patient #2 reported a pain of 10 of 10. S4RN reported that Tylenol was given for the patient's pain. S4RN reported the response to the medication was documented as being unchanged. S4RN verified that there was no documentation to indicate that a follow up pain scale assessment had been completed on Patient #2. S4RN indicated that a follow up pain scale assessment should have been conducted. S4RN indicated Patient #2 was discharged to home with a sling on her right arm.

In an interview on 7/14/15 at 7:30 a.m. with S3MD, he said Patient #2 had presented to the ED on 6/2/15 because of the syncope. S3MD verified Patient #2 had a dislocated shoulder because of a fall. S3MD said he had reviewed old charts from another hospital and Patient #2 had a tumor on her brain. S3MD said he did not reduce her shoulder because he was afraid Patient #2 would have a seizure during the process or have an intracranial hemorrhage. S3MD said Patient #2's shoulder could have been repaired electively. S3MD indicated that he told Patient #2 to follow up with a specialist about her brain tumor and then an Orthopedist about her shoulder. S3MD indicated that he usually set dislocated shoulders and typically did not discharge patients home without reducing the dislocation. S3MD indicated that he felt Patient #2's medical emergent condition was stabilized to the point of discharging her home with the understanding that she would comply with discharge instructions. S3MD indicated that a sling was placed on Patient #2 to immobilize her arm and he felt her condition was stabilized at the time of discharge.

In an interview on 7/14/15 at 7:55 a.m. with S5RN, she said Patient #2 came to the emergency room for passing out and having a hurt shoulder. S5RN said she catheterized Patient #2, gave medicines to her and discharged her from the ED on 6/2/15. S5RN said the doctor makes the decision to treat or not. S5RN said if Patient #2 moved her arm she was in pain, but if it was immobilized she was fine. S5RN said Patient #2 was told to follow up with an orthopedic doctor after discharge.