Based on review of a patient sample of 20 medical records from emergency department (ED) visits, and interview with hospital staff members it was determined that the hospital failed to provide an appropriate medical screening examination, which included ancillary services that were routinely available to the emergency department in order to determine whether or not an emergency medical condition existed. One patient (1) presented to the ED complaining of arm pain after a slip and fall on ice. Patient 1 did not receive an X-ray in order to rule out a fracture.
Findings include:
1. Review of the medical record for patient 1 revealed the following information:
Patient 1 was an eleven year old male who presented at the ED on 1/18/12, with the chief complaint of left shoulder injury resulting from a fall at school.
a. Review of the physicians emergency room report dated 1/18/12, revealed that patient 1 was complaining of an arm injury. The physician documented that patient 1 was complaining of pain in the left humerus area of the arm. The physician documented that the patient landed with his arms outstretched. The physician documented that patient 1 appeared alert and comfortable. The physician documented in his Musculoskeletal assessment that patient 1 had no tenderness to palpation. There was no deformity in the clavicle or AC joint. The physician also documented the following: No tenderness with range of motion passively, but some tenderness with range of motion actively with flexion and extension of the elbow, the area of the tenderness being in the area of the humerus. The physician documented under the section of the report titled Emergency Department Course: The patient is felt to have a muscle strain clinically that shows no evidence of any fracture. There is no tenderness at the shoulder joint or at the elbow, but does have some tenderness at the midshaft of the humerus, but no evidence of any fracture. In any case the plan is to have the patient return here for any escalating symptoms, otherwise follow up with his primary physician. The physician documented that the patient's provisional diagnosis was Left shoulder strain. The physician documented that the patient was to follow up with his doctor in two days if not better.
There was no evidence in patient 1's medical record that an X-ray of the arm or shoulder was ordered or done.
b. Review of the nurse's documentation in patient 1's medical record revealed the following information:
The nurse documented that patient 1's chief complaint was injury to the left shoulder. The nurse documented that the injury occurred about one hour before arrival in the ED. Documentation of the mechanism of injury was: Patient was playing football at school, slipped on the ice and fell , landing on his left shoulder. The nurse documented that the patient complained of pain at 7 on a 1 to 10 pain scale (10 being the worst pain possible). The nurse documented that the patient had limited range of motion in the left shoulder and the patient refused to move his arm. The nurse documented that the patient was discharged after being seen by the physician. The patient complained of a pain level of 6 when discharged .
2. Review of patient 1's medical record revealed that patient 1 had an outpatient X-ray of the left shoulder on 1/26/12. This was eight days after patient 1's ED visit. The X-ray report documented the following: Three views of the left shoulder are evaluated. A slightly angulated slightly impacted fracture of the proximal shaft of the left humerus is present distal to the plate.
3. An interview was conducted with the hospital's quality assurance manager and the facility's chief nursing officer on 2/6/12. The quality assurance manager stated that he noted during his quality reviews that patient 1 had returned to the hospital for an outpatient shoulder X-ray after he had been evaluated in the ED for a shoulder injury. The quality assurance manager and the chief nursing manager stated that it would be unusual for the physician not to order an X-ray for this type of injury. The quality assurance manager stated that he was investigating the incident and the results would be sent to the physician's committee for review.
Review of the sample of medical records revealed that patients who presented in the ED with similar complaints and injuries received medical screening examinations which included X-rays.
