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STATE OF FLORIDA ...
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AGENCY FOR HEALTH CARE ADMINl 'i'f fi<t IE I w IE i 1
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AGENCY FOR HEALTH CARE ;LJ J·LAP·R 1 4 2011 , .:.:'.):
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Petitioner,
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vs.
INDIAN RIVER MEMORIAL HOSPITAL, INC. d/b/a INDIAN RIVER MEDICAL CENTER,
Respondent.
,!
Case No. 2011000761
ADMINISTRATIVE COMPLAINT
COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration · (hereinafter "the Agency"), by and through its undersigned counsel, and files tlus Administrative Complaint against the Respondent, INDIAN RIVER MEMORIAL HOSPITAL, INC. d/b/a INDIAN RIVER MEDICAL CENTER (hereinafter "the Respondent''), pursuant to Sections
120.569 and 120.57, Florida Statutes (2010), and alleges as follows:
NATURE OF THE ACTION
This is an action to impose an administrative fine against a hospital in the amount of TWO
· THOUSAND DOLLARS ($2,000.00) pursuant to Section 395.1041(5)(a), Florida Statutes (2010).
JURISDICTION AND VENUE
The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2010).
The Agency has jurisdiction over the Respondent pursuant to Sections 20.42 and 120.60, Florida Statutes (2010), Chapters 408, Part II, and 395, Part I, Florida Statutes (2010), and
I A
Filed May 3, 2011 2:22 PM Division of Administrative Hearings
Chapter 59A-3, Florida Administrative Code.
· Venue lies pursuant to Rule 28-106.207, Florida Administrative Code.
PARTIES
The Agency is the licensing and regulatory authority that oversees hospitals in Florida and· enforces the applicable federal and state regulations, statutes and rules governing hospitals pursuant to Chapter 408, Part II, Florida Statutes (2010); Chapter 395, Part I, Florida Statutes (2010) and Chapter 59A 3, Florida Administrative Code. The Agency may deny, revoke, suspend a license, or impose an administrative fine, against-a hospital, for the violation of any provision of Chapter 395, Part I, Florida Statutes (2010), or any rule adopted under this part.
The Respondent was issued a license by the Agency to operate a 335-bed hospital (License No. 4029) located at 1000 36th Street, Vero Beach, Florida 32960, and was at all times material required to comply with the applicable federal and state regulations, statutes and rules.
COUNT!
The Respondent Failed To Provide Stabilizing Treatment By The Vascular Surgeon On Call To The Emergency Room When Requested By A Physician Who Conducted The Medical Screening Exam In Violation Of Section 395.002(9), Florida Statutes (2010), And Rule 59A-3.2S5(6)(a), Florida Administrative Code
The Agency re-alleges and incorporates by reference paragraphs one (1) through
.five (5).
Pursuant to Florida law. "emergency services and care" means medical screening, examination, and evaluation by a physician, or, to the extent pennitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of the facility. Section 395;002(9), Florida Statutes (2010).
Pursuant to Florida law, every hospital offering emergency services and care shall
provide emergency care available twenty-four (24) hours a day within the hospital to patients presenting to the hospital. Rule 59A-3.255(6)(a), Florida Administrative Code.
On or about December 20, 2010 through December 21, 2010, the Agency conducted a Complaint Survey (CCR# 2010013029) of the Respondent's facility.
Based on record reviews and interviews, the facility failed to provide stabilizing
· treatment by the vascular surgeon on-call to the emergency room when requested by the emergency room physician who conducted the medical screening exam and identified the change in the medical condition for one (I) of five (5) patients and transferred an unstable patient, Patient
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number one (1).
IO. A review of the privileges by individual provider for the vascular surgeon on-call
to the emergency room on March 2, 2010 included the diagnosis and surgical treatment of •
.vascular injuries in patients of all ages.
A review of the medical staff by-laws, rules and regulations revealed that the medical staff shall maintain an emergency room call schedule by specialty and physicians within the specialty are rotated on-call for a twenty-four (24) hour period. On-call staff must resp6nd to a call within thirty (30) minutes and must attend to the needs of the patient within a reasonable time and appropriate to the patient's condition. The on-call specialist with the assistance of the emergency room physician shall be responsible for the patient's care and treatment until an appropriate disposition is made.
A review of current facility policy for patient screen and stabilization revealed that medical screening shall be·conducted to determine whether the individual has an emergency medical condition; a medical condition with acute symptoms of sufficient severity that could result in serious dysfunction of any body part. A patient found to have an emergency medical condition shall be provided with stabilizing treatment. The facility maintains a list of physicians
who are on-call after the initial examination by the emergency room physician to provide the treatment necessary to stabilize an individual with an emergency medical condition. If the patient's condition remains wistable, treatment shall continue to be provided. The patient y not be discharged, but may still be transferred within the guidelines of the facility policy for transfers ·. to other hospitals or acute care facilities.
A review of the current facility policy for transfers to other hospitals or acute care facilities revealed that the guidelines are that the on-can ·specialist may be consulted and required to come into the facility if deemed necessary by the emergency room physician.
14.
Staff Services revealed that ifthere are partners to the physician taking emergency roo call that wil be covering for the scheduled physician the office must be notified in writing. If there was an
· emergency that prevented the specialist from providing on-call care to the emergency room, a call
.would be made to the emergency room that day and the schedule would be changed. A review of the on-call schedule for the emergency room for specialty physicians revealed that the vascular surgeon on-call was on-call to the Indian River Medical Center emergency room for fourteen (14) days in March 2010 which included March 2, 2010. A review of the documentation provided by the medical staff office confinned that the physician submitted a signed compensation attestation for the fourteen (14) dates of emergency room call, which included March 2, 201O. The Director of Medical Staff Services confirmed that neither vascular surgeon has a partner in his practice. They practice alone.
While reviewing the related complaint at Lawnwood Regional Medical Center on December 2, 2010, the vascular surgeon was interviewed by telephone. An interview on December 2, 2010 at 10:20 am with the vascular surgeon confinned that he was on-call at Indian River Medical Center but was in elective surgery at Lawnwood ·Regional Medical Center when
Indfan River Medical Center called him regarding a patient. Indian River Medical Center patient number one (1). The physician called his partners in to see patient number one (1) and the patient was. transferred to Lawnwood Regional Medical Center. The vascular surgeon stated that he·did not say that he would take patient number one (1) at Lawnwood Regional Medical Center. He reminded the emergency room physician at Lawnwood Regional Medical Center that he was not the vascular surgeon on-call and he had not arranged the transfer.
An interview and clinical record review on December 20, 2010 at 10:00 a.m. with the Director of Emergency and Diagnostic Imaging Services revealed that patient number one-(1) fell outdoors in the rain in the vicinit of home on March 2, 2010. 9-1-1 was called and tient number one (1) was transported to I dian River Medical Center by county rescue. The rescue documentation revealed that patient number one (1) was found on the ground, in the rain with contusions on the face and forehead, acute pain in the right shoulder, contusions on the left knee and left elbow. The blood pressure was 170/100. The emergency room physician examination was at 1 l:03 a.m. in the treatment area. Patient number one (I) reported that he/she fell and struck his/her head, had a headache with no loss of consciousness, no amnesia, a shatp pain in the right shoulder; left elbow and left knee. Patient number one (1) co1,1ld not bear weight to walk. There were palpable pedal pulses and no extremity edema. The emergency room physician ordered CT scans and x-rays and called the orthopedic physician on-call in to see patient number one (1). The CT cervical spine showed no fracture; the CT of the head showed no fracture or hemorrhage; CT of the elbow showed the distal h erus fracture and the fracture and radial head dislocation; the right shoulder x-ray showed an acute dislocation; the left elbow x-ray showed possible distal humerus fracture; the left knee x-ray showed acute posterior dislocation of the tibia on the femur
and an acute dislocation of the left knee and possible tibial plateau fracture; proximal fibular
fracture. At 1:05 pm patient number one (1) gave consent for sedation and the emergency room
s
physician.reduced and realigned the dislocated right shoulder; the left knee·was relocated in-line with a stabilizer. A Velcro knee immobilizer was used. After the procedure, the emergency room physician documented that the distal pulses were intact in all four (4) extremities. At 3:00 p.m. the · orthopedic physician on-call came in to evaluate patient number one (1). After the evaluation, he spoke with two (2) of his partners and they decided to transfer patient number one (1) .to the
trauma center because patien·t number one (1) met the fracture criteria with every fracture
documented on x-ray. Patient number one (I) agreed to the transfer. The trauma center at Lawnwood Regional Medical Center agreed to take patient number one (1). There was physician to-physician acceptance and nurse-to-nurse report to the trauma center at Lawnwood Regional . Medical Center. As the transfer to the trauma center was being ananged, the orthopedic and the emergency room physicians were at the bedside and found the decreased movement and palpable pulse in patient number one's (1) left foot. The vascular surgeon on-call was called for an evaluation of the left knee injury. The documentation by the emergency room physician revealed that the vascular surgeon on-call was reached by phone and wanted patient number one (i) transferred to Lawnwood Regional Medical Center as planned. The emergency room physician described the possibility of a vascular injury and the vascular surgeon on-call said to just send patient number one (1) and that he would likely consult on patient number one (1) at the trauma center. A review of the orthopedic consultation dictated by the on-call orthopedic surgeon on March 2, 2010 at 4:35 pm revealed that patient number one (1) stated that he/she noted that there was numbness in the left foot since_the injury. AU of the extremities were tender to palpation with some swelling. On examination there was no motor function or sensory distal to the left ankle. The emergency room physician. again called the vascular surgeon.on-call and reiterated the time from the injury to the time of decreased pulses and sensation in the left leg. The vascular surgeon on-call was asked to come in to evaluate patient number one (1) and again the vascular surgeon
t .
on-call said to just transfer to the trauma center. A review of the case management notes in the clinical record revealed that patient number one (1) was scheduled for a trauma transfer when the vascular injury was identified. The on-call vascular surgeon was called and decided patient number one (1) was okay to transport and would see patient number one (1) in the trauma center.
An interview on December 20, 2010 at 11:00 a.m. with the Director of Patient Safety and Quality Management confirmed that the vascular surgeon on-call had no partners in his practice. The vascular surgeon was called and responded to the emergency room physician and the on-call orthopedic surgeon. The vascular surgeon refused to come in to see patient number one (1). The vascular surgeon said to transfer atient number one l and he would see the patient at Lawnwood Regional Medical Center. The vascular surgeon talked about the risk of vascular injury but provided no vascular evaluation at Indian River Medical Center. The emergency room staff had the best of intentions to send patient number one (1) to the vascular surgeon on-call for evaluation. They never expected that the vascular surgeon would then refuse to see patient number one (1).
An interview on December 20, 2010 at 11:15 a.m. with the Director of Emergency
and Diagnostic Imaging Services revealed that the orthopedic surgeon on-call identified in a dictated consultation the need for treatment of a vascular injury. The orthopedic surgeon called his partners to verify the vascular injury and immobilized the knee fracture. The vascular surgeon on-call was called to report the orthopedic trauma with possible vascular injury. The orthopedic surgeons agreed that this was a trauma patient and with vascular injury. The need for care was serious. The vascular surgeon on-call responded that he was already at Lawnwood Regional Medical Center and stated that he would likely consult on patient number one (1) in the trauma center.
An interview on December 20, 2010 at 11:30 am with the Medical Director of the
Emergency Room revealed that patient number one (1) had multiple joint injuries. The left knee was potentially complicated with an orthopedic/vascular combination injury. There is a narrow window of time for successful repair of vessels. The orthopedic surgeon wanted patient number one (1) transferred to the trauma center. When the on-call vascular surgeon was called, he refused to come in as he was in the operating room at Lawnwood Regional Medical Center. The emergency room physician spoke with the vascular surgeon and orthopedics twice to confirm the transfer and assessment at Lawnwood Regional Medical Center of the vascular injuries. The Medical Director stated that if the vascular surgeon on-call had refused outright to come, the other . vascular surgeon would have been called, but that is not what happened. The vascular surgeon on- call stated that he would see patient number one (l) in the trauma center. Patient number one (1) had been stabilized orthopedically, but was unstable from a vascular point and should have had vascular surgery at Indian River Medical Center. The vascular surgeon on-call insisted on the transfer and patient number one (1) went to the trauma center.
An interview on December 20, 2010 at 12:30 p.m. with the Chief of the Medical Staff and the only other vascular surgeon on staff at Indian River Medical Center revealed that a surgeon can be on call at Indian River Medical Center and in elective surgery at other facility if he can be reached by phone within thirty (30) minutes. There is no specific rule that does not allow this; however, this will probably change when the Medical Executiv Committee updates the by-laws, rules and regulations. The Chief of the Medical Staff stated that he did not assess or treat patient number one (I), but with any dislocation a nerve injury can happen. There was no detectable blood flow and a call went out to the vascular surgeon on-call. There is a narrow window of time for successful repair of vessels. Patient number one's (1) transfer should have been stopped and vascular assessment should have been done. The vascular surgeon on-call exerted pressure to transport patient number one (1) to him at Lawnwood Regional Medical
8
Center and when patient number one (1) got to the trauma center,-the vascular surgeon on-call was at home stating that he was not on-call at Lawnwood Regional Medical Center. The vascular surgeon did not come in to assess the vascular injury at either facility. A multidisciplinary review was conducted and reported to the Chainnan of the Board at Indian River Medical Center. At the meeting, the review team was critical of the management of the case of patient number one (1). Patient number one (I) should have been stabilized before transfer. The vascular surgeon on-call justified the transfer by stating that patient number one (1) needed the orthopedic and vascular trauma care and Indian River Medical Center orthopedic surgeons could not manage the case and the trauma center could manage it.
The on-call orthopedic surgeon was out on leave. from a bicycle accident and was
unable to be reached by phone. His practice partner was interviewed by telephone on.December 20, 2010 at 12:45 pm. The on-call orthopedic surgeon had examined all of the long bone fractures of patient number one (1) and had consulted two (2) of the partners regarding management of
patient number one (1). The decision was that every long bone was fractured and patient number one (1) would require treatment by trauma surgeons and should be transferred. With the additional possibility of a vascular injury to the knee vessels, the vascular surgeon on-call to the emergency room was called.
An interview on December 20, 2010 at 1:00 p.m. with the Chief Operating Officer_ revealed that the vascular surgeon on•call did not come to Indian River Medical Center to evaluate patient number one (1). According to the Chief Operating Officer, the vascular surgeon did not outright refuse, but he made the emergency room staff believe that patient number one (1) would be seen sooner and managed _better_ if patient number one (1) were sent to Lawnwood Regional Medical Center trauma center. When patient number one (1) arrived at the trauma center, the vascular surgeon on-call was at home stating to the trauma center that he was not on-
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call. The Indian River Medical Center staff did not intentionally send an unstable patient; when they started the transfer process patient number one (1) only had orthopedic injuries. The vascu)a surgeon on-call was called when the lack of circulation was discovered by examination of the emergency room physician and the orthopedic surgeon on-call.
· An interview and review on December 20, 2010 at·l:15 pm with the Director of Emergency and Diagnostic Imaging Services revealed_ that the current facility policy for the criteria for documenting trauma for the purpose of transfer of the patient is that two (2) or more long bones be fractured. The long bones includes the humerus, radius, ulna, femur, tibia or fibula, the systolic blood ressure over 90 a e 55 or over etc. Patient number one I had do
fractures of all the long bones on the criteria list and met the criteria for transfer to the trauma center. The emergency room physician repaired, reduced, strapped and stabilized all of the fractures for transfer. When the emergency room physician and the orthopedic surgeon went to the bedside of patient number one (1), they discovered through interview and examination that there was a vascular injury and called the on-call vascular surgeon.
An interview on December 21, 2010 at 9:20 a.m. by telephone with the emergency.· room physician who treated patient number one (1) revealed that patient number one (1) reported to the orthopedic surgeon at 4:30 pm that his/her left foot had been nurp.b since the fall. The pedal pulses were heard until that interview. Patient number one (1) had not told any other staff about the numbness. The emergency room physician spoke with the vascular surgeon on-call. The vascular surgeon on-call said to send patient number one (1) to Lawnwood Regional Medical Center because he was in surgery there. The vascular surgeon on-call did not outright refuse to come, but did not come into the emergency room at Indian River Medical Center to assess patient number one (1). The vascular surgeon on-call insisted that patient number one (1) be sent to him at Lawnwood Regional Medical Center to be seen. A second call was placed to the vascular
surgeon on-call by the emergency room physician to make sure that he was not coming in to see patient number one (1) since there was a probable injury to the ves ls. The vascular surgeon on
·call kept saying send patient number one (1). The vascular surgeon on-call insisted that he was
there and would see patient number one (1).
An interview on December 21, 2010 at 11:15 a.m. with the Chief Medical Officer revealed that Emergency Medical Treatment and Active Labor Act (EMTALA) training is provided to all physi ians as they come on board staff. The general staff and employed physicians complete risk management updates annually which includes EMTALA training.
An interview on December 21, 2010 at 11:45 a.m. with the vascular surgeon on- call revealed that the emergency room physician called him while he-was in the operating room at Lawnwood Regional Medical Center to say that patient number one (1) had orthopedic injuries· that warranted transfer to the trauma center. Orthopedics had discovered a probable vascular injury and called him to ask what tests needed to be done before transfer. The transfer was already planned. If the vascular surgeon on-call had come into Indian River Medical Center and taken patient number one (1) to the operating room, he would have had to shop around for orthopedic
_surgeons, because the surgeon on-call was not capable of managing the injuries patient number one (1) already had. The vascular surgeon on-call stated that he was not called to come in, but rather to ask what he would suggest before transfer. The trauma center had already accepted patient number one (1). The vascular surgeon on-call does not think that patient number one (1) was unstable, but had done no evaluation or assessment of patient number one (1) in o;rder to make this determination.
While reviewing the complaint at Lawnwood Regional Medical Center on December 2, 2010, it was revealed by five (5) physicians at Lawnwood Regional Medical Center, three (3) vascular surgeons, one (1) emergency room physician, and one (1) trauma surgeon that
once discovering the injury to the knee, patient number one (1) had a six (6) hour window for .· success with a repair of the vessels. After six (6) hours the success rate is greatly reduced. P tient ·· number one (I) went to surgery for the vascular repair more than twenty-four (24) hours after the injury was discovered, thus lessening the odds that the circulation to the area could be successfully restored. The delay in care decreased the success rate of the surgical repair and the subsequent ruvputations and sepsis contributed to the death of patient number one (1). During interviews on December 21, 2010 at Indian River Medical Center, three (3) physicians at Indian River Medical Center; the Medical Director of the Emergency Room, the Chief of Medical Staff and vascular surgeon and a ain with the vascular sur eon on-cal1 the a reed that a ve short window exists for repair to vascular injuries of the knee vessels.
Patient number one (1) was injured at approximately l0:00 a.m: and was admitted to the Indian River Medical Center emergency room and examined by the emergency room physician at 11:00 a.m. Patient number one (1) later stated that he/she had numbness in the left lower- extremity since the fall. The assessments done at Indian River Medical Center identified tlu:tt pedal pulses were present until 4:30 p.m. Patient number one (1) did not have a vascular evaluation once the probability of the injury was identified. The on-call vascular surgeon failed to assess and evaluate the injury at Indian River Medical Center. The vascular surgeon stated that since the trauma transfer was already in progress, why stop it, just send patient number one (1). The unstable patient was transferred at 5:50 p.m. The vascular surgeon refused to see patient
number one (1) once he/she was in the trauma center because the vascular surgeon was not on-call
. .
there that day. The delay in the care to the iajury decreased the success of the surgical repair and contributed to the death of patient number one (1).
The Agency may deny, revoke, suspend a license, or impose an administrative fine, against a hospital, not to exceed $10,000 per violation for the violation of any provision
under Section 395.1041, Florida Statutes (2010), or rules adopted under this Section. Section
395.1041 (5)(a), Florida Statutes (2010).
WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00).
COUNTU
The Respondent Failed To Provide Further Consultation By The Vascular Surgeon On-Call To The Emergency Room When Requested By The Emergency Room Physician Who Conducted The Medical Screening Exam In Violation Of Rule 59A-3.255(6)(a)3, Florida Administrative Code
five (5).
Pursuant to Florida law, every hospital offering emergency services and care shall provide emergency care available twenty-four (24) hours a day within the hospital to patients presenting to the hospital. At a minimum, specialty consultation shall be available by request of the attending physician or by transfer to a designated hospital where definitive care can be provided. Rule 59A-3.255(6)(a)3, Florida Administrative Code.
On or about December 20, 2010 through December 21, 2010, the Agency conducted a Complaint Survey (CCR# 2010013029) of the Respondent's facility.
Based on record reviews and interviews, the facility failed to provide further consultation by the vascular surgeon on-call to the emergency room when requested by the emergency room physician who conducted the medical screening exam and identified a change in the me4ical condition for one (1) of five (5) patients, patient number one (1).
A review of the privileges by in,dividual provider for the vascular surgeon on-call to the emergency room on March 2, 2010 included the diagnosis and surgical treatment of vascular iajuries in patients of all ages.
A review of the medical staff by-laws, rules and regulations revealed that the medical staff shall maintain an emergency room call schedule by specialty and physicians within the specialty are rotated on-call for a twenty-four (24) hour period. On-call staff must respond to a call within thirty (30) minutes and must attend to the needs of the patient within a reasonable time and appropriate to the patient's condition. The on-call specialist with the assistance of the emergency room physician shall be responsible for the patient's care and treatment until an appropriate disposition is made.
A review of current facility policy for patient screen and stabilization revealed that medical screening shall be conducted to determine whether the individual has an emergency · medical condition; a med1cal condition with acute symptoms of sufficient severity that could result in serious dysfunction of any body part.· A patient found to have ail emergency medical condition shall be provided with stabilizing treatment. The facility maintains a list of physicians who are on-call after the initial examination by the emergency room physician to provide the treatment necessary to stabilize an individual with an emergency medical condition. If the patient's condition remains unstable, treatment shall continue to be provided. The patient may not be discharged, but may still be transferred within the guidelines of the facility policy for transfers to other hospitals or acute care facilities.
A review of the current facility policy for transfers to other hospitals or acute care facilities revealed that the guidelines are that the on-call specialist may be consulted and required to come into the facility if deemed necessary by the emergency room physician.
An interview on December 20, 2010 at 9:15 a.m. with the Director of Medical Staff Services revealed that if there are partners to the physician taking emergency room calls that would be covering for the scheduled physician, the office must be notified in writing. If there was an emergency that prevented the specialist from providing on-call care to the emergency room, a
call would be made to the emergency room that day and the schedule would be changed. A review of the on-call schedule for the emergency room for specialty physicians revealed that the vascular surgeon on-call was on-call to the Indian River Medical Center emergency room for fourteen (14)
days in March 2010 which included March 2, 2010. A review of the documentation provided.by
. the medical staff office confirmed that the physician submitted a signed compensation attestation for the fourteen (14) dates of emergency room call, which included March 2, 2010. The Director
of Medical Staff Services confirmed that neither vascular surgeon has a partner in his practice. They practice alone.
While revie ·
December 2, 2010, the vascular surgeon was interviewed by telephone. An interview on December 2, 2010 at 10:20 a.m. with the vascular surgeon confirmed .that he was on-call at Indian River Medical Center but was in elective surgery at Lawnwood Regional Medical Center when Indian River Medical Center called him regarding a patient, Indian River Medical Center patient number one (1). The physician called his partners in to see patient number one (I) and the patient · was transferred to Lawnwood Regional Medical Center. The vascular surge n stated that he did . not say that he would take patient number one (1) at Lawnwood Regional Medical Center. He reminded the emergency room physician at Lawnwood Regional Medical Center that he was not the vascular surgeon on-call and he had not arranged the transfer.
An interview and clinical record review on December 20, 2010 at 10:00 a.m. with the Director of Emergency and Diagnostic Imaging Services revealed that patient number one (1) fell outdoors in the rain in the vicinity of home on March 2, 2010. 9-1-1 was called and patient number one (1) was transported to Indian River Medical Center by county rescue. The rescue documentation revealed that patient number one (1) was found on the ground in the rain with contusions on the face and forehead, acute pain in the right shoulder, and contusions on the left
IS
knee and left elbow. The blood pressure was.170/100. The emergency room physician examination was at 11:03 a.m. in the treatment area. Patient number one (I) reported that he/she fell and struck his/her head, had a headache with no loss of consciousness, no amnesia, a sharp pain in the right shoillder, left elbow and left knee. Patient number one (t)·could not bear weight to· walk. There were palpable pedal pulses and no extremity edema. The emergency room physician ordered CT_ scans and x-rays and called the orthopedic physician on-call in to see the patien:t. The CT scan of the cervical spine showed no fracture; the CT scan of the head showed no fracture or hemorrhage; CT scan of the elbow showed the distal humerus fracture and the fracture and radial head dislocation· the ri t shoulder x-ra
ray showed possible distal humerus fracture; the left knee x-ray. showed acute posterior
dislocation of the tibia on the femur and an acute dislocation of the left knee and possible tibial plateau fracture; proximal fibular fracture. At 1:05 p.m. patient number one (l) gave consent for
_sedation and the emergency room physician reduced and realigned the dislocated right shoulder; the left knee was relocated in line with a stabilizer. A Velcro knee immobilizer was used. After the procedure, the emergency room physician documented that the distal pulses were intact in all four (4) extremities. At 3:00 p.m. the ortb,opedic physician on-call came in to evaluate patient number one (1). After the evaluation, the orthopedic physician spoke with two (2) of his partners and they decided to transfer patient number one (1) to the trauma center because he/she met the fracture criteria with every fracture documented on x-ray. Patient number one (1) agreed to the transfer. The trauma center at Lawnwood Regional Medical Center agreed to take patient number one (1). There was physician-to-physician acceptance and nurse•to-nurse report to the trauma
center at Lawnwood Regional Medical Center. As the transfer to the trauma center was being arranged, the orthopedic and the emergency room physicians were at the bedside and found the decreased movement and palpable pulse in the patients left foot. The vascular surgeon on call was
..
called for an evaluation of the left knee injury. The documentation by the emergency room physician revealed that the vascular surgeon on-call was reached by phone and wanted patient number one (1) transferred to Lawnwood Regional Medical Center as planned. The emergency room physician described the possibility of a vascular injury and the vascular surgeon on-call said to just send patient number one (1) and that the vascular surgeon would likely consult on the patient at the trauma center. A review of the orthopedic consultation dictated by the on-call
orthopedic surgeon on March 2, 2010 at 4:35 p.m. revealed that patient number one (1) stated that he/she noted that there was numbness in the left foot since the injury. All of the extremities were
tender to al ation with some swellin . On examination there was no motor functio · o
distal to the left ankle. The emergency room physician again called the vascular surgeon on-call and reiterated the time from the injury to the time of decreased pulses and sensation in the left leg. The vascular surgeon on-call was asked to come.in to evaluate patient number one (1) and again the vascular surgeon on-call said to just transfer to the trauma center. A review of the case management notes in the clinical record revealed that patient number one (1) was scheduled for a trauma transfer when the vascular injury was identified. The on-call vascular surgeon was called and decided patient number one (l) was okay to transport and would see the patient in the trauma center.
An interview on December 20, 2010 at 11:00 a.m. with the Director of Patient Safety and Quality Management confinned that the vascular surgeon on-call had no partners in his practice. The vascular surgeon was called and responded to the emergency room physician and the on-call orthopedic surgeon. The vascular surgeon refused to come in to see patient number one (1). The vascular surgeon said to transfer patient number one (1) and he would see the patient at Lawnwood Regional Medical Center. The vascular surgeon talked about the risk of vascular injury but provided no vascular evaluation at Indian River Medical Center. The
J
. . .
emergency room staff had the best of intentions ·to send patient number one (1) to the vascular
.surgeon on-can·ror evaluation. They never expected that the vascular surgeon would then refuse
to see patient number one (1).
An interview on December 20, 2010 at 11:15 a.m. with the Director of Emergency and· Diagnostic Imaging Services · revealed that the orthopedic surgeon on-call identified in a dictated consultation the need for treatment of a vascular injury. The orthopedic surgeon called his partners to verify the vascular injury and immobilized the knee fracture. The vascular surgeon on-call was called to report the orthopedic trauma with possible vascular injury. The orthopedic
was serious. The vascular surgeon on-call responded that he was already at Lawnwood Regional Medical Center and stated that he would likely consult on the patient in the trauma center.
An interview on December 20, 2010 at 11:30 a.m. with the Medical Director of the Emergency Room revealed that patient number one (1) had multiple joint injuries. The left knee · was petentially complicated with an orthopedic/vascular combination injury. There is a narrow window of time for successful repair of vessels. The orthopedic surgeon wanted patient number one (1) transferred to the trauma center. When the on-call vascular surgeon was called, he refused to come in as he was in the operating room at Lawnwood Regional Medical Center. The emergency room physician spoke with the vascular surgeon and orthopedics twice to confirm the transfer and assessment at Lawn.wood Regional M;edical Center of the vascular irtjuries. The Medical Director stated that if the _vascular surgeon on-call had refused outright to come, the other vascular surgeon would have been called, but that is not what happened. The vascular surgeon on call stated that he would see patient number one (1) in the trauma center. Patient number one (1) had been stabilized orthopedically, but was unstable from a vascular point and should have had vascular surgery at Indian River Medical.Center. The vascular surgeon on-call insisted o_n the
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•!, •·'
. transfer and patient number one (1) went to the trauma center.
An interview on December 20, 20IO at 12:30 p.m. with the Chief of the Medical Staff and the only other vascular surgeon on staff at Indian River Medical Center revealed that a surgeon can be onMcall at Indian River Medical Center and in elective surgery at another facility if he can be reached by phone within thirty (30) minutes. There is no specific rule that does not · allow thisJ however, this will probably change when the Medical Executive·Committee updates the by laws, rules and regulations. The Chief of th Medical Staff stated that he did not assess or treat patient number one (1) but, with any dislocation a nerve injury can happen. There was no detectable blood flow and a call went out to the vascular sur eon onMcall. There is a narrow window of time for successful repair of vessels. The patient transfer should have been stopped and vascular assessment should have been done. The vascular surgeon onMcall exerted pressure to transport patient number one (1) to him at Lawnwood Regional Medical Center and when patient number one (1) got to the trauma center, the vascular surgeon onMcall was at home stating that he was not on call at Lawnwood Regional Medical Center. The vascular surgeon did not come in to assess the vascular injury at either facility. A multidisciplinary review was conducted and reported to the Chairman of the Board at Indian River Medical Center. At the meeting the review team was critical of the management of the case of patient number one (l). The patient should have been stabilized before transfer. The vascular surgeon on-call justified the transfer by stating that patient number one (1) needed the orthopedic and vascular trauma care and Indian Rive_r Medical Center orthopedic surgeons could not manage the case and the trauma center could manage it.
The on-call orthopedic surgeon was out on leave from a bicycle accident and was unable to be reached by phone. His practice partner was interviewed by telephone on December 20, 2010 at 12:45 p.m. The on-call orthopedic surgeon had examined all of the long bone
fractures of patient number one (I) and had consulted two (2) of the partners regarding management of the patient. The decision was that every long bone was fractured and patient number one (1) would require treatment by trauma surgeons and should be transferred. With the
additional possibility of a vascular injury to the knee vessels, the vascular surgeon on-call to the emergency room was called.
An interview on December 20, 2010 at 1:00 p.m. with the Chief Operating Officer· revealed that the vascular surgeon on-call did not come to Indian River Medical Center to evaluate patient number one (1). According to the Chief Operating Officer, the vascular surgeon ·
did not outright refuse, but he made the emergency room staff believe that patient number one (1)
would be seen sooner and managed better if he/she were sent to Lawnwood Regional Medical Center trauma center. When patient number one (1) arrived at the trauma center, the vascular
·surgeon on-call was at home stating to the trauma center that he was not on-call. The Indian River
Medical Center staff did not intentionally send an unstable patient; when they started the transfer process patient number one (1) only had orthopedic injuries. The vascular surgeon on-call was called when the lack of circulation was discovered by examination of the emergency room physician and the orthopedic surgeon on-call.
An interview and review on December 20, 2010 at 1:15 p.m. with the Director of Emergency and Diagnostic Imaging Services reve led that the current facility policy· for the criteria for documenting trauma for the purpose of transfer of the patient is that two (2) or more long bones be fractured. The long bones include the humerus, radius, ulna, femur, tibia or fibula, the systolic blood pressure over 90, age 55 or over, etc. Patient number one (I) had docwnented fractures of all the long bones on the criteria list and met the criteria for transfer to the trauma center. The emergency room physician repaired,. reduced, strapped and stabilized all of the fractures for transfer. When the emergency room physician and the orthopedic surgeon went to
the bedside of patient number one (1), they discovered through interview and examination that ·
. there was a vascular injury and called the on-call vascular surgeon.
An interview on December 21, 2010 at 9:20 a.m. by telephone with the emer ency room physician who treated patient number one (1) revealed that patient number one (1) reported · to the orthopedic surgeon at 4:30 p.m. that his/her left foot had been numb since the fall. The pedal pulses were heard until that interview. Patient number one (1) had not told any other staff about the numbness. The emergency room physician spoke with the_vascular surgeon on-call. Th·e vascular surgeon on-call said to send patient number one (1) to Lawnwood Regional Medical Center because he was in sur there. The vascular sur eon on-call did not outri ht refuse to come, but did not come into the emergency room at Indian River Medical Center to assess patient number one (1). The vascular surgeon on-call insisted that patient number one (1) be sent to him at Lawnwood Regional Medical Center to be seen. A second call was placed to the vascular surgeon on-call by the emergency room physician to make sure that he was not coming in to see patient number one (1) since there was a probable injury to the vessels. The vascular surgeon on call kept saying send patient number one (1). The vascular surgeon on-call insisted that he was there and would see patient number one (1).
An interview on December 21, 2010 at 11:15 a.m. with the Chief Medical Officer
revealed that Emergency Medical Treatment and Active Labor Act (EMTALA) training is provided to all physicians as they come on board staff. The general staff and employed physicians complete risk management updates annually which includes EMTALA training.
An interview on December 21, 2010 at 11:45 a.m. with the vascular surgeon on- call revealed that the emergency room physician called him while he was in the operating room at Lawnwood Regional Medical Center to say that patient number one (1) had orthopedic injuries· that warranted transfer to the trauma center. Orthopedics had discovered a probable vascular
injury and called the vascular surgeon to ask what tests needed to be done before transfer. The transfer was already planned. If the vascular surgeon on-call had come into Indian River Medical Center and taken patient number one (1) to the operating room, the vascular surgeon would have had to shop around for orthopedic surgeons, because the surgeon on-call was not capable of managing the injuries patient number one (1) already had. The vascular surgeon on-call stated that he was not called to come in, but rather to ask what he would suggest before transfer. The trauma center had already accepted patient number one (1). The vascular surgeon on-call does not think that patient number one (1) was unstable, but had done no evaluation or assessment of the patient in order to make this determination.
While reviewing the complaint at Lawnwood Regional Medical Center on December 2, 2010 it was revealed by five (5) physicians at_Lawnwood Regional Medical Center; three (3) vascular surgeons, one (1) emergency room physician, and one (1) trauma surgeon that once discovering the injury to the knee, patient number one (1) had a six (6) hour window for success with a repair of the vessels. After six (6) hours the success rate is greatly reduced. Patient number one (1) went to surgery for the vascular repair more than twenty-four (24) hours after the injury was discovered, thus lessening the odds that the circulation to the area could be successfully restored. The delay in care decreased the success rate of the surgical repair and the subsequent amputations and sepsis contributed to the death of patient number one (1). During interviews on December 21, 2010 at Indian River Medical Center, three (3) physicians at Indian River Medical Center; the Emergency Room Medical Director, the Chief of Medical Staff and vascular surgeon and again with the vascular surgeon on-call, they agreed that a very short window exists for repair to vascular injuries of the knee vessels.
Patient number one (1) was injured at approximately 10:00 a.m. ano was admitted to the Indian River Medical Center emergency room and examined by the emergency room
physician at 11:00 a.m. Patient number one (1) later stated that.he/she had numbness in the left lower extremity since the fall. The assessments done at Indian River Medical Center identified that pedal pulses were present until 4:30 p.m. Patient number one (1) did not have a vascular· evaluation once the probability of the injury was identified. The on-call vascular surgeon failed to assess and evaluate e injury at Indian River Medical Center. The vascular surgeon stated that since the trauma transfer was already in progress, why stop it, just send patient number one (I). the unstable patient was transferred at 5:50 p.m. The vascular surgeon refused to see patient number one (1) once he/she was in the trauma center because the vascular surgeon was not on-call there that day. The delay in the care to the injury decreased the success of the surgical re air and contributed to the death of patient number one (1).
The Agency may deny, revoke, suspend a license, or impose an administrative fine, against. a hospital, not to exceed $10,000 per violation for the violation of any provision under ·Section 395.1041, Florida Statutes (2010), or rules adopted under this section. Section 395.1041(5-)(a), Florida Statutes (2010).
WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00).
CLAIM FOR RELIEF
WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to grant the following relief:
Enter findings of fact and conclusions of law in favor of the Agency as set forth above.
Impose an administrative fine in the amount of TWO THOUSAND DOLLARS ($2,000.00) against the Respondent.
-.
Order any other relief that the Court deems just and appropriate. Respectfully submitted this M day of .,,,L .2011.
ary aley Jao s:Assistant General Counsel Florida Bar No. 0355712
Agency for Health Care Administration Office of the General Counsel · 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901
Telephone: (239) 335-1253
NOTICE.
ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS.
ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRJJIE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA
. 32308; TELEPHONE (850) 412-363•0.
THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY.
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CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form has been served to: Jeffrey L. Susi, Chief Executive Officer and Registered Agent for Indian River Memorial Hospital, Inc. d/b/a Indian River Medical Center,
1000 36th Street, Vero Beach, Florida 32960, by U.S. Certified Mail, Return Receipt No. 7009 ·
1680 0001 5449 4455, on this _tu!U,-.
day of tJr«-1. , 2011.
;J aley J ,Assistant Oeneral Counsel Florida Bar No. 0355712
Agency for Health Care Administration
Office of the General Counsel
2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Telephone:·(239) 335-1253
Copies furnished to:
Jeffrey L. Susi, Chief Executive Officer and Registered Agent for Indian River Memorial Hospital, Inc. d/b/a Indian River Medical Center 1000 36th Street Vero Beach, Florida 32960 (U.S. Certified Mail) | Mary Daley Jacobs, Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C .Fort Myers, Florida 33901 (Interoffice Mail) |
Arlene Mayo-Davis, Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach. Florida 33484 (U.S. Mail) |
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| Issue Date | Proceedings |
|---|---|
| Aug. 23, 2011 | (Agency) Final Order filed. |
| Aug. 23, 2011 | Settlement Agreement filed. |
| May 26, 2011 | Order Closing File. CASE CLOSED. |
| May 26, 2011 | Motion to Relinquish Jurisdiction filed. |
| May 16, 2011 | Order of Pre-hearing Instructions. |
| May 16, 2011 | Notice of Hearing (hearing set for June 21 and 22, 2011; 9:00 a.m.; Vero Beach, FL). |
| May 11, 2011 | Joint Response to Initial Order filed. |
| May 04, 2011 | Initial Order. |
| May 03, 2011 | Agency action letter filed. |
| May 03, 2011 | Notice of Appearance (filed by B. Lamb). |
| May 03, 2011 | Administrative Complaint filed. |
| May 03, 2011 | Notice (of Agency referral) filed. |
| May 03, 2011 | Petition for Hearing Involving Disputed Issues of Material Fact filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Aug. 22, 2011 | Agency Final Order |
