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UNIVERSITY OF VERMONT MEDICAL CENTER 111 COLCHESTER AVE BURLINGTON, VT 05401 Nov. 2, 2011
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on staff interview and record review the hospital failed to ensure that an appropriate Medical Screening Exam (MSE), to determine whether or not an Emergency Medical Condition (EMC) existed, was conducted for Patient #1 who presented to the Emergency Department after being hit by a car while in their motorized wheelchair and complained of a headache and back pain. Findings include:

On 7/9/11 at 7:13 PM Patient #1 was brought via ambulance to the Emergency Department (ED) after being struck by a car while crossing a street in their motorized wheelchair. The patient sustained an abrasion to the right side of the back of head and complained of a headache and low back pain. The patient's past history includes a spinal defect and had a ventriculoperitoneal shunt (a tubing that drains excess fluid from the brain) (VP shunt) in place.

During the course of the Medical Screening Exam, Provider #1 prescribes Zofran, ( anti nausea medication ) and Dilaudid (a narcotic) for the patient's headache. A Shunt series (x-rays of the skull, chest and abdomen to visualize the placement and integrity of the VP shunt) was also ordered by Provider #1. Per Radiology report at 9:53 PM on 7/9/11 the findings of the Shunt series were discussed by a Radiology Resident with Provider #1. Per interview on 10/31/11 at 1:55 PM Provider #1 stated s/he was informed by Radiology "the test was normal".

At 11:03 PM, accompanied by a family member, Patient #1 was discharged to home from the ED with a final diagnosis of "Motor Vehicle Accident; closed head injury and abrasion of head or scalp". Within 11 hours of discharge, on 7/10/11 Patient #1 was pronounced dead with cause of death listed as a brain injury and skull fracture due to blunt impact of head and manner of death listed as "accident".

Although an MSE was conducted, on 7/9/11, Provider #1 confirmed s/he failed to order a CT scan ( Cross sectional images of an area of the inside of the body, reveals more details then regular x-ray; can be used to detect bleeding, brain injury, strokes and skull fractures) of Patient #1's head stating on 10/31/11 at 2:00 PM, "I assumed it (the Shunt series) included a CT of the head."

However , per review of Patient #1's medical record, Provider #1 had documented that s/he had conducted an "Independent visualization of images .... " and acknowledged within the electronic record s/he had reviewed Patient #1's " CT scan and labs ". During interview, Provider #1 confirmed s/he had not looked at the Shunt series x-ray films or a CT of the head (since a head CT was never ordered) nor had s/he read the radiology report of the Shunt series. In addition, s/he confirmed if they had reviewed the Shunt films it would have been apparent a head CT scan was not performed. Furthermore, if Provider #1 had read the dictated report from Radiology of the Shunt series s/he would have also come to the same conclusion, a CT scan of Patient #1's head was not performed. Failure to conduct a CT scan of Patient #1's head, limited the opportunity to utilize results of more definitive testing when completing a MSE. This failure resulted in Provider #1 not effectively identifying Patient #1 was experiencing an Emergency Medical Condition.

Per interview on 11/1/11 at 3:00 PM, the former ED Physician Clinical leader (who is now the hospital's Chief of medical Staff) at the time Patient #1 received treatment on 7/9/11, confirmed upon being informed of the death of Patient #1 s/he contacted Provider #1 and was informed by Provider #1 s/he was not aware the Shunt series did not include a CT scan. The ED Physician Clinical leader also stated it is " Best practice " and his/her's expectation that the ordering practitioner in the ED should be reviewing results of all diagnostic testing they have ordered on patients, although there is no written facility policy regarding this expectation. S/he also stated most practitioners would know that a Shunt series does not include a CT of the head. S/he further stated " In the ED it would be very unusual to not get a head CT with a Shunt series ".

Per interview on 11/2/11 at 11:04 AM, the Interim CEO (and previous Chief Quality Officer on 7/9/11) confirmed the hospital conducted an internal investigation within 24 hours of the event. Immediate corrective action included a warning notice posted within the electronic record alerting practitioners the following process instructions: " Shunt series consist only of AP/Lat films. If you desire CT or MRI imaging, you must order it separately". Through medical staff meetings and electronic mail practitioners were made aware of the event and the changes to prevent a further incident. In addition, The Interim CEO also stated the Board of Trustees was kept informed of the event and corrective action process.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on staff interview and record review the hospital failed to ensure stability of the medical condition prior to discharge for Patient #1, as evidenced by the hospital's failure to complete an appropriate MSE to determine if an EMC existed. Findings include:

On 7/9/11 at 7:13 PM Patient #1 was brought via ambulance to the Emergency Department (ED) after being struck by a car while crossing a street in their motorized wheelchair. The patient sustained an abrasion to the right side of the back of head and complained of a headache and low back pain. The patient's past history includes a spinal defect and had a ventriculoperitoneal shunt (a tubing that drains excess fluid from the brain) (VP shunt) in place.

During the course of the Medical Screening Exam, Provider #1 prescribes Zofran, ( anti nausea medication ) and Dilaudid (a narcotic) for the patient's headache. A Shunt series (x-rays of the skull, chest and abdomen to visualize the placement and integrity of the VP shunt) was also ordered by Provider #1. Per Radiology report at 9:53 PM on 7/9/11 the findings of the Shunt series were discussed by a Radiology Resident with Provider #1. Per interview on 10/31/11 at 1:55 PM Provider #1 stated s/he was informed by Radiology "the test was normal".

At 11:03 PM, accompanied by a family member, Patient #1 was discharged to home from the ED with a final diagnosis of "Motor Vehicle Accident; closed head injury and abrasion of head or scalp". Within 11 hours of discharge, on 7/10/11 Patient #1 was pronounced dead with cause of death listed as a brain injury and skull fracture due to blunt impact of head and manner of death listed as "accident".

During the MSE of Patient #1 performed by Provider #1 on 7/9/11 s/he confirmed on 10/31/11 at 2:00 PM this did not include a head CT scan ( Cross sectional images of an area of the inside of the body, reveals more details then regular x-ray; can be used to detect bleeding, brain injury, strokes and skull fractures). S/he further stated "I assumed it (the Shunt series) included a CT of the head."

However , per review of Patient #1's medical record, Provider #1 had documented that s/he had conducted an "Independent visualization of images .... " and acknowledged within the electronic record s/he had reviewed Patient #1's " CT scan and labs ". During interview, Provider #1 confirmed s/he had not looked at the Shunt series x-ray films or a CT of the head (since a head CT was never ordered) nor had s/he read the radiology report of the Shunt series. In addition, s/he confirmed if they had reviewed the Shunt films it would have been apparent a head CT scan was not performed. Furthermore, if Provider #1 had read the dictated report from Radiology of the Shunt series s/he would have also come to the same conclusion, a CT scan of Patient #1's head was not performed. Failure to conduct a CT scan of Patient #1's head, limited the opportunity to utilize results of more definitive testing when completing a MSE. As a result, Provider #1 failed to ensure stabilization of Patient # 1's Emergency Medical Condition prior to discharge.

Per interview on 11/1/11 at 3:00 PM, the former ED Physician Clinical leader at the time Patient #1 received treatment on 7/9/11, confirmed upon being informed of the death of Patient #1 s/he contacted Provider #1 and was informed by Provider #1 s/he was not aware the Shunt series did not include a CT scan. The ED Physician Clinical leader also stated it is " Best practice " and his/her's expectation that the ordering practitioner in the ED should be reviewing results of all diagnostic testing they have ordered on patients, although there is no written facility policy regarding this expectation. S/he also stated most practitioners would know that a Shunt series does not include a CT of the head. S/he further stated " In the ED it would be very unusual to not get a head CT with a Shunt series ".

Per interview on 11/2/11 at 11:04 AM, the Interim CEO (and previous Chief Quality Officer on 7/9/11) confirmed the hospital conducted an internal investigation within 24 hours of the event. Immediate corrective action included a warning notice posted within the electronic record alerting practitioners the following process instructions: " Shunt series consist only of AP/Lat films. If you desire CT or MRI imaging, you must order it separately". Through medical staff meetings and electronic mail practitioners were made aware of the event and the changes to prevent a further incident. In addition, The Interim CEO also stated the Board of Trustees was kept informed of the event and corrective action process.