HospitalInspections.org

Based on review of medical records, medical staff bylaws and interviews, it was determined that a patient who presented to the Emergent Department (ED) with an emergent situation left and went to another hospital for treatment when the on-call Orthopedic surgeon failed to come see the patient as required by this hospital's established Medical Staff Bylaws, Rules and Regulations 2013, (patient record #9).

The findings were:

1. The Medical Staff Bylaws, Rules and Regulations as revised 2013, were reviewed May 13, 2013 beginning at 3 PM, in the hospital's Administrative Conference room. A portion of those Bylaws read in part,
"3. The following rules shall govern the conduct of physicians who are on-call to the Emergency Department at Henrico Doctors' Hospital:...

b. During the time the physician is scheduled to be on-call, the on-call physician or a qualified substituting physician shall be available for consultation within a reasonable period of time. While a reasonable timeframe is case/patient specific an initial response by telephone or in person, should not normally exceed 30 minutes. The on-call physician has the responsibility to secure the qualified alternate in the event that he/she is unavailable.

c. ...If the expertise of an on-call physician is needed, then the on-call physician would be obligated to provide care deemed necessary by the Emergency Department physician for completion of the medical screening exam."

2. Review of the patient's (#9) medical record revealed that on March 9, 2013 at 1703 (military time) a 56 year old male presented to the Emergency Department with complaints of "Right hand index finger trauma." The patient was triaged (initially assessed) by a registered nurse (employee #7) which was also time stamped as 1703 and documented in the triage note, "Subjective: Right hand index finger crush/injury with decreased sensation.
Objective: Alert & oriented, responding appropriately, follows commands skin warm dry, MAE (Mental alertness evaluation) x 4, no acute distress, bleeding controlled with pressure by patient."
The documentation also revealed that the patient's neurological, CV (cardiovascular), and respiratory status were all, "WDP" (within defined parameters). Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.

The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, the Physician's Assistant (PA ), employee #9, ordered an X-ray of the injured finger and that X-ray report read, "Open fracture of the base of the distal phalanx of the second finger with slight distraction."

The Physician's Assistant (employee #9) documented a "HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 read in part,
HPI
Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.
Source of history: patient ...
Review of Systems
Skin: laceration
Neuro: Reported numbness (to tip of R index finger), tingling (to tip pf R index finger)
Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present
Past Medical History Reports: none

Consultation #1 physician #4 (Hand Orthopod) who was not on-call
Call returned, He cannot come back in tonight. He says I can put a few loose stitches in the finger, and the patient can come back at 8:30 am tomorrow, and he will meet him here for repair. I can try to get someone else on-call.

Consultation: 2 (Orthopod on-call)
Call returned, physician #2 called back. I explained that the pt (patient) was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:
I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else."

The patient left the Emergency Department at 1815.

The patient's electronic record was signed by the PA at 1842.
The supervising physician note read, "The PA/NP's chart was reviewed. I agree with the assessment and care plan, and confirm the diagnosis." The note was electronically signed by physician #1

3. The hospital's Chief Medical Officer (physician. #5) was interviewed on May 14, 2013 beginning at 1155 in the Administrative Conference room. Physician #5 stated that he became aware of this incident on or about March 13, 2013 at which time he reviewed the patient's medical record and then proceeded to make phone calls. Physician #2 was called and asked about the situation. Physician #2 told the Chief Medical Officer (CFO) that he was not asked to come in and if they would have asked him to come he would have. The CFO said that they discussed the consequence of this incident and reviewed/re-educated on what should have occurred and specific aspects of the hospital's Bylaws in regard to on-call services. The CFO also said that he called the patient and listened to what the patient had to say. The conversation covered the incident, the patient's expectations, the hospital's expectations in providing quality care and that this incident would be investigated internally. The CFO then stated that at the end of the telephone conversation the patient seemed satisfied.

4. The Vice President (VP) of Quality and Risk Management was interviewed multiple times during the onsite investigation. On May 14, 2013 beginning at 12 noon in the Administrative Conference room the VP of Quality and Risk stated that this incident has been discussed at the Peer Review committee meeting for surgery on April 24, 2013. The committee has requested that physician #2 respond in writing to the committee the circumstances surrounding this case. The incident is also being presented at the medical Peer Review Committee on May 22, 2013.

5. Interviews were attempted but unsuccessful with the Physician Assistant (employee #9), physician #2 and the complainant.

Based on medical record review, Medical Staff Bylaws, Rules and Regulations 2013 and interview, it was determined the facility's Emergency Department failed to conduct an appropriate and accurate medical screening examination for one (1) of twenty (20) patients in the survey sample, medical record #9.

The findings were:

1. The Medical Staff Bylaws, Rules and Regulations as revised 2013 were reviewed May 13, 2013 in the hospital's Administrative Conference room. A portion of those Bylaws read in part,
"3. The following rules shall govern the conduct of physicians who are on-call to the Emergency Department at Henrico Doctors' Hospital:...

b. During the time the physician is schedules to be on-call, the on-call physician or a qualified substituting physician shall be available for consultation within a reasonable period of time. While a reasonable timeframe is case/patient specific an initial response by telephone or in person, should not normally exceed 30 minutes. The on-call physician has the responsibility secure the qualified alternate in the event that he/she is unavailable.

c. The Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists or a woman is in labor. Such screening must be done within the facility's capabilities (including the use of ancillary services) and available personnel, including on-call physicians or physician's assistants. If the expertise of an on-call physician is needed, then the on-call physician would be obligated to provide care deemed necessary by the Emergency Department physician for completion of the medical screening exam."

2. Review of the patient's (#9) medical record revealed that on March 9, 2013 at 1703 (military time) a 56 year old male presented to the Emergency Department with complaints of "Right hand index finger trauma." The patient was triaged by a registered nurse (employee #7) which was also time stamped as 17:03 and documented in the triage note, "Subjective: Right hand index finger crush/injury with decreased sensation.
Objective: Alert & oriented, responding appropriately, follows commands skin warm dry, MAE (Mental alertness evaluation) x 4, no acute distress, bleeding controlled with pressure by patient."
The documentation also revealed that the patient's neurological, CV (cardiovascular), and respiratory status were all, "WDP" (within defined parameters). Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.

The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, a Physician's Assistant (employee #9) ordered an X-ray of the injured finger and that X-ray report read, "Open fracture of the base of the distal phalanx of the second finger with slight distraction."

The Physician's Assistant (employee #9) documented a "HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 and read in part,
HPI
Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.
Source of history: patient ...
Review of Systems
Skin: laceration
Neuro: Reported numbness (to tip pf R index finger), tingling (to tip pf R index finger)
Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present
Past Medical History Reports: none

Consultation #1 physician #4 (Hand Orthopod) who was not on-call
Call returned, He cannot come back in tonight. He says I can put a few loose stitches in the finger, and the patient can come back at 8:30 am tomorrow, and he will meet him here for repair. I can try to get someone else on-call.

Consultation: 2 (Orthopod on-call)
Call returned, physician #2 called back. I explained that the pt (patient was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (another Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:
I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else."

The patient left the Emergency Department at 1815.

The record failed to contain documented evidence that the injured index finger was assessed by the consulted on-call Orthopedic physician

3. When the patient left the hospital (#1), he went to hospital #2. Review of the medical record from the 2nd hospital reveals that the patient was arrived at hospital #2 on 3/9/13 at 1834 and was triaged (an initial assessment) beginning at 1841 by a registered nurse. Triage documentation read in part, "Past medical History: cardiac stent (a plastic tube inside an artery in the heart to keep it open), MI (heart attack), HTN (high blood pressure) and high chol (high cholesterol), a fatty substance in the blood)." The patient rated his pain level at a 6 on a scale of one (1) to ten (10). A detailed EMS (Emergency medical screening) was conducted and time stamped 3/9/13 1933.
Another X-ray of the finger was performed and revealed "A near transection of the distal aspect of the second digit is noted with a horizontal fracture ... The remainder of the bones and soft tissue are otherwise intact and unremarkable."
A consult with a plastic surgeon was ordered and a portion of that documentation read, "Right index finger with partial amputation of tip just proximal to nail, tissue intact on volar surface, tissue appears viable, sensation to sharp intact distally at tip, nail intact. Clean wounds with sterile saline (salt water) and chlorhexidine scrub (a liquid antiseptic that removes bacteria on the skin). Repaired skin with 4.0 nylon sutures. Splinted distal finger with metal splint."

The patient left the Emergency Department at 9:57 PM with prescriptions and discharge instructions.

Based on clinical record review and interview, it was determined that the facility failed to have documented evidence in the clinical record that the facility provided and or offered stabilizing treatment to one (1) of one (1) patient's in the survey sample who had an emergent medical condition, refused the proposed treatment and left to seek care at another facility, patient #9.

The findings were:

Review of the patient's (#9) medical record in its entirety revealed that on March 9, 2013 at 1703 (military time) a 56 year old male presented to the Emergency Department with complaints of "Right hand index finger trauma." The patient was triaged by a registered nurse (employee #7) which was also time stamped as 17:03 and documented in the triage note, "Subjective: Right hand index finger crush/injury with decreased sensation.
Objective: .... Pain was assessed using a numeric scale and on a scale of one (1) to ten (10) with one (1) being the least amount of pain, the patient was experiencing pain at a intensity of 5.
The triage note did not contain documentation of any visualization or assessment of the injured finger. The patient returned to the waiting room and was never assigned a bed in the Emergency Department, he remained in the waiting room the entire time except for the time spent in x-ray.

At 1717, a Physician's Assistant (employee #9) ordered an X-ray of the injured finger and that X-ray report read, "Open fracture of the base of the distal phalanx of the second finger with slight distraction."

The Physician's Assistant (employee #9) documented a "HPI- Extremity Inj Upper (History physical information- Upper Extremity Injury) which was time stamped as 3/9/13 1820 and read in part,
HPI
Complaint: finger injury, The patient injured his finger, crushed his R index finger on some equipment. The R index finger is amputated, only hanging on by some skin. He is a XX (medical professional) and needs his finger repaired.
Source of history: patient ...
Review of Systems
Skin: laceration
Neuro: Reported numbness (to tip pf R index finger), tingling (to tip pf R index finger)
Hand: Finger injury (amputation), type of finger injury (amputation R index finger), laceration, limited range of motion, neurologic deficit pre (present), vascular deficit present
Past Medical History Reports: none.

Consultation: #2 (Orthopod on-call)
Call returned, physician #2 called back. I explained that the pt (patient was a X (medical professional) and knows Dr. (another Ortho doctor). I told him he had an amputation to the right index finger, only hanging on by a thread. He said that I can take the finger off and flap the area, give him antibiotics and tetanus, and Dr (another Ortho doctor) will see him next week. I told him again my concerns, and he repeated what he said initially.

Additional notes:
I (employee #9) spoke with physician #1 (Emergency Department doctor) about the issue. She said that he could be transferred to XX (another hospital) if he requests, otherwise we have called all of our contacts. I explained to the patient what the on-call doctor said. He (the patient) was very upset. I offered to give a digital block, but he declined. He wanted the doctor's name on-call and was going to leave and go somewhere else."

The patient left the Emergency Department at 1815.

The record failed to contain documented evidence that the patient was offered stabilizing treatment prior to the patient leaving the Emergency Department. The record also failed to contain any documentation of the injured index finger wound being cleansed, the dressing from home being removed and a clean dressing applied, antibiotics or a Tetanus Booster being offered or provided.