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HARRISON MEDICAL CENTER 2520 CHERRY AVENUE BREMERTON, WA 98310 Feb. 8, 2012
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and review of medical records, it was determined that the hospital failed to comply with CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases.

Findings include:

As detailed in Tag 2406, it was determined that the hospital failed to provide an appropriate medical screening examination to 2 of 29 patients whose emergency department (ED) medical records were reviewed and, therefore, failed to comply with CFR ?489.24.

Reference Tag 2406
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and review of medical records, it was determined that the hospital failed to provide an appropriate medical screening examination to 2 of 29 patients whose emergency department (ED) medical records were reviewed. The hospital's failure to do so resulted in 2 patients having undiagnosed injuries which required subsequent treatment, one of which was an emergency surgery, and potentially placed all patients of the ED at risk for incomplete/inappropriate medical screening examinations with a subsequent risk for undiagnosed injury or illness.

Findings include:

Patient #1
The complainant stated that Patient #1 and Patient #2 had been in the same vehicle which was involved in a head-on motor vehicle accident (MVA) on 12/30/2011. Both patients were transported from the site of the MVA to the Harrison Memorial Hospital ED in Bremerton, where they were evaluated and treated by ED physicians.

The complainant stated that Patient #1 had suffered injuries to both lower extremities and while in the ED on 12/20/2011, her/his open laceration to the left lower leg was treated [sutured and dressed], but her/his right foot was not xrayed. The complainant stated that the patient had complained to the staff of pain in the right foot, but the ED physician refused to xray the foot and told the patient the foot was only bruised.

The complainant also stated that Patient #1 returned to the ED several times for dressing changes to the left lower leg. The patient reportedly told each physician s/he saw over the course of treatment that the pain in the right foot was increasing, but "they just dismissed it". The complainant stated that each physician s/he told about the right foot pain performed the same "flexion" test on the foot and stated that the foot was only bruised.

The complainant stated that the pain continued to increase and there was significant swelling in both lower extremities; therefore, the patient eventually sought help from a physician outside of the hospital. The outside physician xrayed the foot, told the patient s/he had a broken foot, and reportedly fitted the patient with a walking boot.

A review of the medical records for Patient #1 revealed the following:

ED visit of 12/30/11: The visit was immediately after the MVA. ED physician documentation reveals "examination of the right lower extremity: [H/she] is moving it ad lib." No additional documentation regarding the right lower extremity/foot was found.

The physician ordered a cardiac monitor, EKG, CT scan of the head, CT scan of the neck, CT scan of the chest, CT scan of the abdomen and pelvis and an xray of the tib/fib [lower leg] area of the left leg, as well as intravenous solutions, medications and laboratory tests.

ED visit of 1/3/2012: The patient was seen in the ED for complaint of increased swelling in both lower extremities and a dressing change to the left leg. ED physician notes documented that the patient was advised to keep both lower extremities elevated.
Nursing notes for the visit document: "Pt. is now also c/o [complaining of] R foot pain" and further notes by nursing documented that the pain was rated 7 on a scale of 1-10.

The physician ordered a TdaP [tetanus, [DIAGNOSES REDACTED] and pertussis] immunization. No imaging studies or other tests/medications/interventions were ordered, and no documentation was found to support that the physician specifically evaluated the right foot.

ED visit of 1/6/2012: The patient was seen in the ED with complaint of continued swelling in both lower extremities. ED physician documentation stated "...knees and legs hit the dash in front of of [her/him]...telling me that [s/he] has developed swelling in [her/his] legs and [s/he] is not sure why."

The patient's lower extremities were evaluated with a Doppler scan [to evaluate patently of vessels/presence of blood clots]. The patient was placed on a cardiac monitor and laboratory tests were ordered, the patient's left leg wound was re-dressed; no additional imaging studies were ordered.

ED visit of 1/7/2012: The patient was seen in the ED for complaints of increased pain and swelling, but documentation does not indicate if the complaints were relative to one or both legs. ED physician notes indicate that the sutures in the left leg were removed, a culture was obtained, the wound was re-dressed and the patient was started on an intravenous antibiotic for acute cellulite.

ED physician documentation also revealed that the ED physician contacted the radiologist "concerning the ultrasound obtained yesterday to once again see if there is any evidence of foreign body or a significant area indicating abscess, and he said albeit it was a limited study, there is no obvious evidence of either issue..." The documentation did not state which leg was the subject of the discussion.

ED visit of 1/8/2012: The patient was seen in the ED to have her/his left leg wound rechecked. The patient's leg was re-evaluated and the physician ordered multiple laboratory tests, as well as a CT scan with contrast of the patient's abdomen and pelvis. The ED physician documented "...does have a Wheaton or a seatbelt sign in [her/his] mid-abdomen...a CT scan was repeated since it was not initially done with contrast, which did not show any acute findings except for some inflammation..."

Outside Physicians' Clinic visit of 1/11/2012: Documentation from the physician at the outside clinic revealed that the patient had presented to the clinic for evaluation of multiple injuries sustained from the MVA of 12/30/2011. Physician's documentation stated "...continues to have bilateral foot, ankle, leg and knee pain and is frustrated that the ER did not and has not taken XRays of [her/his] legs even with repeated reports of significant pain, worse in [her/his] right foot". The physician ordered xrays of both feet and the documentation relative to the right foot was:

"FINDINGS: Three views of the right foot were obtained. There is a mildly displaced fracture involving the base of the second metatarsal extending to the proximal articular surface.
IMPRESSION: Fracture involving the second metatarsal base with intra-articular involvement."

The ED physician who originally provided care for Patient #1 on 12/30/2011 was unavailable for interview. Physician #2, the physician who subsequently treated the patient on 1/3/2012, was interviewed, and stated that as s/he recalled, the patient's primary complaint was "a lot of swelling" with both legs, but there was no complaint specifically about the right foot.

The complainant left voice mails for the investigator on 2/14, 2/15 and 2/16/2012 and in each message, stated that Patient #1 had since been evaluated at another hospital and reportedly told that s/he would have to have "reconstructive" surgery on the right foot. The patient reportedly was told that the increased damage to the foot was due to her/his not being diagnosed and treated appropriately at the time of injury, and therefore, not taking the proper precautions to protect the foot.

The hospital's failure to provide "...an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists..." resulted in Patient #1 having an undiagnosed , and untreated, medical emergency.

Patient #2
Patient #2 was in the same vehicle as Patient #1, and was involved in the same MVA on 12/30/2011. The complainant stated that they were both seen and treated in the ED at the Bremerton campus of Harrison Memorial Hospital, and both were discharged to home from the ED.

The complainant stated that Patient #2 had sustained injuries to her/his chest during the MVA and had complained to the staff of chest pain. The complainant stated that the staff assured both Patient #1 and Patient #2 that Patient #2 had been thoroughly evaluated.

The complainant stated that the injuries to the chest of Patient #2 were so severe that, as of 2/8/2012, the patient still had been unable to lie down and had been sleeping in a recliner chair.

A review of the medical records for Patient #2 revealed the following:

On 12/30/2011, the patient presented to the ED via emergency medical services, and was on a backboard with a neck collar in place. The multi-disciplinary system history and physical, signed by the physician, noted that the chief complain was "sternal and c-spine [neck] pain".


The ED physician's documentation noted that the clavicles and chest wall were examined. The differential diagnoses included [DIAGNOSES REDACTED]"

Neck and chest x-rays were ordered and the interpretive readings were:
Xray cervical spine: "No acute bony abnormality. Mild to moderate multilevel degenerative changes, worse at C4-C5 level."
Xray chest: "...cardiomediastinal silhouette and pulmonary vasculature appear within normal limits. There is no pleural effusion or pneumothorax..."

No additional imaging studies were ordered, nor was an EKG or a cardiac monitor ordered.

Nurses notes include, but are not limited to, the following:
17:52 [5:52 pm] "...restrained passenger...c/o pain mid-sternum, clavicle...also c/o neck pain and back pain..."
17:57 [5:57 pm "...c/o pain L shldr across chest, neck and back...:

At 19:07 [7:07 pm], the patient was discharged to home. Physician's clinical impression was 1. acute cervical strain, 2. contusion, chest and 3. evaluation of motor vehicle crash.

On 2/13/2012, Physician #1 was interviewed about the care provided to Patient #2 during her/his initial ED visit on 12/30/2011. The physician stated that s/he had received a verbal report from the emergency medical services (EMS) team, and did not have the benefit of the EMS written report at the time s/he evaluated the patient.

Physician #1 stated that s/he had started her/his evaluation with a chest xray to evaluate for narrowing or widening of the mediastinum [internal area of the chest] and that an electrocardiogram would not necessarily be indicated.
The physician also stated that s/he had considered injury to the spleen when examining the patient, but acknowledged that documentation did not contain any reference to same. The physician also stated that had the radiologist's report on the chest xray identified the fractured sternum, it would have driven her/his examination differently.

On 2/14/2012, I interviewed Radiologist #1 who had provided interpretation of the chest xray of 12/30/2011. The radiologist confirmed that s/he had reviewed the chest xray since the original reading, and in retrospect could see that a sternal fracture was present at the time of initial evaluation.

Radiologist #1 stated while an xray could show injury to the sternum, a CT scane would be more detailed.

On 1/3/2012, Patient #2 returned to the ED with a complaint of increased chest pain, a feeling of "fullness" in the chest and inability to take a deep breath.

On this visit, the patient was treated by Physician #2. The ED physician documentation revealed the following:

"I discussed with [her/him] that I would like to do a chest x-ray on [her/him] to make sure [s/he] has not developed a pneumothorax or atelectasis or pneumonia or pleural effusion or hemothorax, and I ordered a chest x-ray and it shows the sternal fracture...small amount of fluid in the left hemithorax...a little bit tentatively concerned about the spleen...I would like to include that area as well. The CAT scan of the chest also shows the sternal fracture...CAT scan of abdomen does indeed show a splenic rupture and I added the pelvis, once I saw that the spleen was ruptured and it looks like a grade 4 splenic rupture with some active bleeding and a fairly moderate to large amount of blood in the abdomen and pelvis...
DIAGNOSES:
1. Acute ruptured spleen with active bleeding
2. Acute sternal fracture

"...I think [s/he] had a delayed bleed that suddenly became worse and more significant...s/he worsened while [s/he] was here. My suspicion is that [her/his] prior exam would have been such that a ruptured spleen would not and should not have been considered in the differential diagnosis."

Imaging tests that were ordered include the following:
-Chest xray
-CT scan of chest, with contrast
-CT scan of abdomen, with contrast
-CT scan of pelvis, with contrast

Radiologist's interpretation of the imaging studies:
-Chest xray:
1.) mid-sternal contour deformity that likely represents an acute fracture
2. Contour deformities of left eighth and ninth ribs suspicious for nondisplaced rib fractures
3.) Small left pleural effusion

-CT chest, with contrast
1.) Nondisplaced left lateral rib fractures from the left fifth through eighth ribs without pneumothorax
2.) Mid sternal nondisplaced fracture
3.) Hemoperitoneum with ruptured spleen and extravasation of contrast...

-CT of the abdomen and pelvis, enhanced
Nondisplaced left lateral rib fractures involving the fifth through eighth ribs

Radiologist #2, who interpreted the imaging studies taken on 1/3/2012, stated that for the sternum, a plain film [xray] or CT scan could be used and for the spleen, either an ultrasound or CT scan would be preferred.

On 1/3/2012, the patient was admitted to the hospital from the ED and subsequently underwent a splenectomy [removal of the spleen].

On 2/14/2012, Physician #2 was asked about the preferred imaging for diagnosing injury to the sternum and/or spleen, and stated that it was not necessary to image the sternum because "you don't treat the fracture anyway", but for imaging the spleen, a CT or ultrasound would be preferred.

The physician also acknowledged that it was fortunate that the patient had returned to the ED when s/he did, because otherwise the patient would have died .

The hospital's failure to provide "...an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists..." resulted in Patient #2 having an undiagnosed ruptured spleen, fractured sternum and 4 fractured ribs. The ruptured spleen was a medical emergency which was life-threatening.