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LOVELACE MEDICAL CENTER 601 DR MARTIN LUTHER KING JR AVE NE ALBUQUERQUE, NM 87102 Dec. 17, 2015
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the governing body failed to ensure that the medical staff acted on reports of wrist pain and a fall by Patient #1 reported to the physician in the emergency department (ED) on 10/31/15. Patient #1 was discharged to home despite his elevated blood pressure and without assessment and treatment of his fractured wrist. This caused the patient to seek care at another hospital (Hospital #2) which confirmed the injury of a fractured wrist, received at the hospital (Hospital #1). The findings are:

A. On 12/17/15 at 8:00 am during interview, the Patient #1 stated he went to the emergency department of Hospital #1 on 10/31/15 at 3:30 pm with chest pain. Patient #1 stated that while waiting for staff to come to his ED room he had a sharp chest pain and rolled off the gurney. Patient #1 stated that 4 hospital staff members came into his ED room to assist him back on the gurney. He stated he informed the physician that both of his wrists were hurting from the fall and that he was given an electrocardiogram (EKG, a record of heart rhythms) in response. Patient #1 stated he was given discharge instructions to follow up with his primary care provider in 3 to 5 days. Patient #1 stated he only told the ED physician, not other staff, about his wrists hurting. Patient #1 was discharged to home by Hospital #1 without assessment of his pain or any treatment. Patient #1 stated that he continued to have right wrist pain and he went to another hospital (Hospital #2) on 11/02/15 and was told his wrist was fractured.

B. Record review of Hospital #1's ED physician assessment conducted on 10/31/15 of Patient #1 indicated the following: "Per pt. pt [patient] denies recent cardiac evaluation. Records show pt underwent stress test x 5 months ago for cp [chest pain]. Results of test were nml [normal]. 10/31/15 17:13 [5:30 pm] pt feeling better, states pain constant several days, same pain as prior episodes, states fell of bed after xray because pain was so severe, repeat ekg shows no changes. Recent admit [admission] for same pain, dx [diagnosis] non cardiac, cp [chest pain] neg [ative] results. States he does not know if he has had prior chest CT [computed tomography, computer-processed x-rays]. Will order one. Pt c/o [complained of] B/L [bilateral] hand pain, will give pain medication for the issue. 10/31/15 17:25 [5:25 pm] pt requesting narcotics, states has not been on narcotics recently, NM [New Mexico] Drug Monitoring program shows recent rxs [prescriptions] in past several months for Vicodin and Percocet [combination pain medicines]. Advised pt will give pain medicine in ED but must fu [follow-up] with pcp [primary care provider] for chronic pain medications."

C. Record review of the policy of the hospital (Hospital #1) on Fall Risk Identification and Prevention, Document # P-NS-108.6, effective date of 08/07/14, indicated the following:
"1. Purpose: 1.1 To guide all disciplines including In-patient units, Emergency Department and Out-Patient Departments in the management and responsibility for all patients who may be at risk for falls. It is not to be used a substitute or replacement for independent clinical assessment and judgment.
1.2 To manage the physical environment of the 'at risk' patients.
1.3 To direct all disciplines in the management of any patient that has fallen.
2. Definitions: Patient Fall - An unplanned descent to the floor (or extension of the floor, such as a trash can or other equipment) with or without injury to the patient. All types of falls are to be included whether they result from physiological reasons (fainting) or environmental reason (slippery floor.) Include assisted falls when a staff member attempts to minimize the impact of the fall. (Exclude falls by visitors, students, and staff members). ....
4.4 If a Fall Occurs:
4.4.1 Provide care as patient condition requires
4.4.2 Assess patient vital signs, level of consciousness and physical condition prior to moving patient. Reassess as needed.
4.4.3 Notify the attending physician or designee on call.
4.4.4 Notify House Supervisor. ...
4.5 Document the following in the medical record:
4.5.1 Circumstances surrounding the fall as known at the time.
4.5.2 Assessment data.
4.5.3 Restraints, if in use
4.5.4 Notifications, who and time notified.
4.5.4 Care and treatment provided to the patient, if any
4.5.5 Complete a post fall debriefing form (Midas focused study entry)."

D. Record review of the policy of the hospital (Hospital #1) on Notification Procedure to Risk Management, document # P-QM-1017.1, effective date of 01/27/2015, indicated the following:
"1. Risk Management:
1.1 Risk Management is in the process of identifying, reporting and mitigating situations that may place the organization in jeopardy of legal action or possible loss of accreditation/licensure.
2. When to Contact Risk Management:
2.1 Any adverse medical and/or surgical outcome
2.2 Physical harm to any person while at the [hospital] campuses including falls with fracture or significant injury."

E. On 12/17/15 at 2:35 pm, an interview was conducted with Registered Nurse (RN) #1, Manager of the Emergency Department of Hospital #1. RN #1 stated she has worked for the hospital since 2009 with most of her experience in the emergency department. RN #1 explained the process of discharging a patient from the emergency department. RN #1 stated that only an RN can discharge the patient and that the RN should get a set of discharge vitals (clinical vital signs, such as heart rate, blood pressure, and respiratory rate). She stated that the RN reviews the discharge paperwork with the patient and addresses any concerns with the patient. RN #1 was asked if she would have discharged a patient with a blood pressure of 150/105. RN #1 stated she would have brought that blood pressure to the attention of the MD and she would have not discharged a patient with a blood pressure that high. RN #1 stated, "Discharging a patient with a blood pressure that high is considered high risk." RN #1 did not recall Patient #1 as a patient on 10/31/15.

F. Record review of Hospital #1's Emergency Department Discharge Transition Record revealed the following:
1. Patient #1 chief complaint was chest pain.
2. Procedures and test performed during ED visit including: complete blood count, cardiac studies, comprehensive metabolic panel, 12 lead EKG, and x-ray of chest.
3. Patient #1 instructed to see his primary care provided in 3 to 5 days.
4. Patient #1 had no new medications at discharge.
5. Discharge record for Patient #1 did not mention patient's complaint of wrist pain.
G. Record review of Hospital #2's Emergency Department record dated 11/02/15 revealed the following:
1. "[name of patient] is a 44 y.o. [year old] M [male] with h/o [history of] HTN [hypertension, or in other words high blood pressure] presenting to the ED for CP [chest pain] x 5 days. He reports intermittent substernal CP which he describes as burning. Pt [patient] states that the episodes last - 5 minutes. He denies change with exertion or eating. He notes associated SOB [shortness of breath]. He denies cough, fever, N/V/D [nausea/vomiting/diarrhea], and leg swelling. Pt was seen at [Hospital #1] for the same sx [symptom]. Unknown diagnosis. Pt states that he fell out of his bed while at [Hospital #1] and landed on his hands, and he now c/o [complains of] rt [right] wrist pain. No other injuries. No h/o [history of] HLD [[DIAGNOSES REDACTED], or in other words abnormally high concentration of fats or lipids in the blood], DM [diabetes mellitus], DVT [deep vein thrombosis, or in other words a blood clot in a peripheral vein], or PE [pulmonary embolism, or in other words a blood clot in the lungs]. No recent travel or surgery. Denies smoking. Occasional ETOH [alcohol]. No current or past drug use."
2. X-ray final results revealed a dorsal triquetral (wrist) fracture with associated dorsal wrist soft tissue swelling.