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Based on policy reviews, dedicated emergency department (DED) record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.24 by failing to provide an appropriate medical screening examination (MSE) for 2 of 37 sampled patients presenting to the hospital's DED (#7, #30) and failing to provide stabilizing treatment within it's capacity for 1 of 1 sampled patients presenting to the hospital's DED that was discharged with an emergency medical condition (#7).

The findings include:

1. ~Cross refer to 489.24(r) and 489.24(c), Medical Screening Exam - Tag A2406.

2. ~Cross refer to 489.24(d)(1-3), Stabilizing Treatment - Tag A2407.

Based on policy review, medical record review, physician and staff interviews, the hospital failed to provide an appropriate medical screening examination with ongoing monitoring for a patient with an emergency medical condition in 2 of 37 sampled patients presenting to the hospital's dedicated emergency department (#7, #30).

The findings include:

A review of current hospital policy "EMTALA Compliance, Including patient Transfers (Emergency Medical Treatment and Labor Act)" (Reviewed 10/2008) revealed "A medical screening examination will be performed on any person presenting to the hospital who either personally, or for whom any person, requests emergency service or care to determine whether or not an emergency medical condition exists." The policy further revealed "Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Serious impairment to bodily function and serious dysfunction of any bodily organ or part." Documentation further revealed "If it has been determined by qualified medical personnel that an emergency medical condition exists: Treatment will be provided by the hospital, the emergency physician, and when medically necessary, by the on-call specialist physician, to relieve, eliminate or stabilize the emergency medical condition within the capabilities of the staff, ancillary services and facilities available to the hospital."

1. Closed dedicated emergency department (DED) medical record review on 11/17/2010 for patient #7 revealed, a 51 year old male who presented to hospital "A's " main campus DED on 10/16/2010 at 0428 via emergency services helicopter after being hit as pedestrian by another vehicle. The patient was triaged at the hospital's DED as a trauma patient with a documented primary evaluation conducted. Documentation revealed that the patient at triage had pain in his "Left lower leg and all over his body" with the pain rated as "6 of 10" with 10 being the most severe pain. The documentation of the patient's vital signs at the time of triage (0428) revealed that the patient's heart rate was "105" and blood pressure at 108/70. Documentation of the patient's pain levels revealed that the patient continued to report his pain level as "6 of 10" until 0615.

Documentation from the patient's medical record revealed the hospital's DED resident physician #1 examined the patient at 0451 on 10/16/2010. The documentation from the DED resident physician revealed that the patient was a "Pedestrian struck by car, complaint of Left Leg and Right Shoulder pain." Further documentation revealed that the patient was "Middle aged male possible MR (Mentally Retarded) versus ETOH (Alcohol) intoxication status post pedestrian versus car; complaint of right upper extremity pain, left lower extremity pain, Cat scan of head/cervical spine cat scan pending, vitals within normal limits, exam otherwise unremarkable. Will reassess after cat scan of head/cervical spine cat scan result- discharge home with strict return to emergency department." No further documentation was found from the DED physician resident #1.

Documentation from the patient's medical record further revealed that the patient was seen by DED physician resident #2 after a change of shift for the residents. The documentation revealed from resident #2 at 0722 "No complaint of pain, patient awake and *** (not legible) at baseline mental status, exam unchanged, negative CT scan. All questions from family, patient and group home representative." The documentation from the resident also revealed "will discharge to group home with pain medications. Follow up with primary medical doctor in 1-2 days. Plan reviewed with group home worker."

Documentation from the DED attending physician (no time documented) assigned to the patient revealed "Seen at bedside with Dr.___ (DED physician resident #1), he was struck by a car and has multiple abrasions. Right shoulder pain. He has Glasgow Coma Scale 15, chest clear, (not legible documentation), pelvis stable, He'll need X-ray, CT and reevaluation." No further documentation was found from the attending physician.

Documentation from the DED nursing staff for 10/16/2010 revealed at 0730 that the patient was "Resting quietly. No complaints, Family at bedside. Normal Saline infusing without problems." Documentation by the nursing staff at 0830 revealed, "Adaptors d/ced times 2, Abrasions dressed with sterile dressing with bacitracin (Antibiotic cream). Patient walked in room. Discharged with caregiver and family."

The review of the medical record for 10/16/2010 revealed that the patient was discharged from the hospital's DED at 0830. No documentation was found where the patient received any pain medications during the visit in the DED from 0425 through 0830. The review further revealed that the patient was given discharge diagnosis by the DED physicians as "Abrasions and Alcohol Abuse". The patient was documented as stable and discharged home according to the documentation.

Documentation review on 11/17/2010 of the patient's closed medical record from hospital "B's" DED for 10/16/2010 revealed that the patient presented to that hospital's DED at 1031 after leaving hospital "A" with a complaint of "family stating the patient was hit by a car after wondering away from group home." The family also reported that the patient had been airlifted to hospital "A" and the family was notified about 0430 (10/16/2010) this AM of patient arrival to hospital "A". Patient was discharged and family called PCP (Primary Care Provider) and was instructed to the ECC (No definition known)."

Documentation of the DED physician's report for 10/16/2010 at hospital "B" revealed that the patient had chief complaint of "Leg Pain." The documentation revealed that "hospital "A" evaluated and discharged the patient. The patient had spoken with his primary medical doctor because the patient is now refusing to walk and complaining of significant pain in his legs." The documentation from the physical examination of the DED physician at hospital "B" revealed that "the patient does have a significant hematoma to the left side of the face. The patient has significant abrasions to the left lateral knee, significant tenderness to the medial and lateral joint lines of the knee. Minimal left ankle tenderness over the lateral malleous. The patient had significant tenderness to the right elbow again, with multiple abrasions there." The documentation review revealed that the DED physician at hospital "B" ordered further radiological testing for the patient. Further documentation by the DED physician at hospital "B" revealed "Evaluation from __hospital "A" was radiology tests which were reevaluated here in the emergency department by myself. The patient had a CT head, which is read as no acute brain abnormality; CT cervical spine, showing no acute fracture. The patient had one view of the shoulder, right shoulder: No evidence of fracture. Pelvis: No fracture, dislocation, or subluxation, and a chest x-ray showing mild pulmonary congestion. In addition, here abdomen and pelvis were obtained showing no acute intra-abdominal injury. Right elbow x-ray showing a nondisplaced fracture through the right radial head, with associated joint effusion. Left knee showing minimally displaced fracture, posterior aspect of the left lateral femoral condyle." Documentation for treatment by the DED physician at hospital "B" revealed " The patient was put in a knee immobilizer on the left lower extremity. Arm was splinted with a sugar tong splint on the right arm. Orthopedics at ___ (hospital "B") was consulted, Dr. ___(orthopedic physician #1 on call hospital "B") who recommended transfer back to hospital "A" with multiple extremity fractures, status post auto-pedestrian. The Dr.___ feels that he should be followed by trauma. Hospital "A" was contacted. Transfer accepted by Dr.___ (Physician #2 at hospital "A")." The documentation revealed that the patient was discharged by transfer from hospital "B" to hospital "A" by emergency medical services transport. The diagnosis from hospital "B's" DED physician was documented as "Radial head fracture and Femoral condyle fracture." Documentation in the DED record at hospital "B" further revealed that the patient did receive pain medication "Morphine Sulfate 4 milligrams" and anti nausea medication "Zofran 4 milligrams" intravenously while a patient at the hospital.

Review on 11/17/2010 of the open medical record for patient #7 revealed that the patient presented to hospital "A's" DED again on 10/16/2010 at 1650 by emergency medical services after being transferred from hospital "B's" DED for further treatment and admission. The documentation from hospital "A's" triage nurse at 1711 revealed "This morning discharged from emergency department after evaluation, pedestrian struck by Motor Vehicle. Patient transferred from ___(hospital "B's") emergency department for evaluation of left femur fracture and right elbow fracture. Abdomen distended, denies pain." Documentation by the same registered nurse from triage documented that the patient's pain level was rated as "10 on scale of 1-10" in lower left leg with description as sudden, sharp and shooting" at 1702.

Review of the medical record's "Orthopaedic Service History and Physical" for 10/16/2010 at 2200 revealed the "patient has effusion noted on left knee. Left lower extremity tender knee and ankle. Right elbow-nondisplaced radial fracture, left femoral condyle fracture." The orthopaedic history and physical diagnosis was documented by the physician as "Right non-displaced radial head fracture and left lateral femoral condyle fracture." The documentation of the plan of care by the orthopaedic physician at hospital "A" revealed "Admit patient, plan for ORIF (open reduction and internal fixation surgery) left femoral condyle fracture, obtain consents, right arm sling for comfort, non weight bearing, Medicare clearance." The documentation revealed that patient #7 was admitted (10/16/2010) to the hospital and discharged during the investigation on 11/18/2010 (34 days later).

An interview on 11/17/2010 at 1248 with the DED physician resident #1 from hospital "A" revealed that she remembered the patient presenting to the DED by helicopter with reports of being hit by a car. The interview revealed that the DED physician resident was working the shift of 1900 (10/15/2010) through 0500 (10/16/2010) and was the first physician to examine the patient. The interview revealed that at triage the patient had primary trauma workup conducted. "I did not know the underlying conditions of the patient. I do not remember deformity of the patient's knee. I am familiar with the patient's outcome when he left our emergency department." The interview revealed that the DED physician resident signed off around 0500 and turned the case over to another DED physician resident. The interview also revealed that the attending physician in the DED does examine patients along with the residents. The DED physician resident revealed that she treated the patient for the symptoms that he had at the time of the presentation. The interview also revealed "I would have gotten same tests, maybe if there longer or a change in clinical status, I would have gotten other testing to discover the fractures. The patient did not receive any medications for pain that I remember."

An interview on 11/17/2010 at 1540 with the DED physician resident #2 from hospital "A" revealed that he started shift on 10/16/2010 at 0600 and did remember patient #7. "I took over for DED resident physician #1 and took over the care for the patient. I remember the patient seen after helicopter trauma evaluation. A survey was done of the patient, imaging done for stabilization. I remember visiting with family and some people from the group home in the patient's room. I also remember the patient having a MR (mental retardation) history. It was difficult to determine the patient's pain level. I talked with mother or someone with the patient denying pain. I did not pick up on the knee tenderness. I missed it. The nurse got the patient to ambulate on our orders and I did not actually see the patient ambulate. I do not remember examining the patient. I missed the tenderness in the knee that the fracture was at. That would have triggered the x-rays." The interview revealed that the DED physician resident did know that the patient had fractures discovered after discharge from the hospital. The interview also revealed that the DED physician resident #2 did not discuss the patient's condition with any attending physician in the DED before discharge. The interview also revealed that the patient did not receive any medications while in the DED, only a prescription for pain medications at the time of discharge.

An interview on 11/18/2010 at 1115 with the DED attending physician for patient #7 revealed that the physician did see the patient at bedside with the DED physician resident #1. "The patient was a trauma case. After trauma he went to different areas in the emergency department. CT's were negative and he went home. I would do same process if it happened again. Care would be the same. I feel it was appropriate medical screening and stability for the patient. As a rule for those traumas, "If they can walk, they can go." The interview also revealed that a patient being able to walk would not 100% rule out a fracture in a patient." The interview also revealed that the attending physician did not see the patient walk, it was the nurse. The patient also was discharged after the DED attending physician left the shift at 0700. The interview also revealed that no examination for tenderness was done that he knew about for the patient. The interview further revealed the physician asked why the patient would be checked for "tenderness."

An interview on 11/18/2010 at 0934 with the DED nurse assigned to patient #7's discharge revealed "The physician resident (#2) wanted the patient to get up and walk. A male caregiver was with him to assist from the group home. One of our technicians helped him to dress. Patient wanted to use the bathroom. He had to be reinforced due to his MR. No expression of pain was noted. The patient did not complain of pain that I can remember. I told the physician that he walked to the bathroom and he was discharged by wheelchair. I do not remember how he walked. He was mentally handicapped so he had slow walk anyhow. I do not remember the patient's receiving any pain medications in the emergency department.

Consequently, patient #7 presented to hospital "A's" DED by helicopter after being struck by a vehicle while laying in the road on 10/16/2010. The patient was examined by two (2) DED physician residents and an attending DED physician at hospital "A". The patient complained of leg pain and overall pain and had imaging in the trauma protocol done. No imaging tests were done for the patient's leg or elbow. The patient was discharged from hospital "A's" DED without pain medications being administered or other imagining tests for his leg and elbow. The interviews with hospital "A's" DED resident physicians and attending physicians revealed that all three physicians failed to examine the patient's documented tenderness in his knee area. The patient was taken to another hospital's DED (hospital "B") after leaving hospital "A" and was diagnosed as having left leg femur condyle fracture and right elbow fracture. Consultation from the hospital "B's" oncall orthopaedic physician recommended that the patient be transferred back to hospital "A" due to the extend of the fractures and injuries with trauma services needed. The patient was transferred back to hospital "A's" DED and admitted under the orthopaedic services for the needed surgical procedures. The patient was admitted to hospital "A" from 10/16/2010 through 11/18/2010 (34 days).


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2. Closed dedicated emergency department (DED) record review on 11/17/2010 for patient #30 revealed a 32 year old female who presented ambulatory to the hospital's main campus DED on 06/30/2010 at 1621 with complaints of neck pain secondary to a motor vehicle accident. Record review revealed the patient was triaged at 1707 by a registered nurse (RN). Record review revealed the patient's initial vital signs at triage were: Temperature 97.9 Degrees Fahrenheit, Pulse 77, Blood Pressure 133/88, Respiration 18, and Oxygen Saturation 97% on room air. Further review revealed an initial pain assessment performed by the triage RN revealed the patient's pain was described as acute sudden left sided neck pain with tightness, onset 2 hours prior to arrival to the DED. Record review revealed the patient's pain level was assessed using a numerical rating scale 0 (no pain) to 10 (worst pain). The patient was assessed as having a pain intensity of 4 out of 10. Record review revealed the patient was assigned an Acuity level: 4 Less Urgent.

Record review revealed nursing documentation at 1735 "patient seen and treated at triage by Dr. (DED physician 3's name)."

Review of a physician's order form dated 06/30/2010 revealed, at the bottom right of the form, "D/C" (discharge) was circled, timed, and signed by DED physician 3 at 1720.

Review of the "ED discharge summary" revealed the patient was given a list of patient education materials for a Motor Vehicle Accident, General Precautions, and Cervical Sprain/Strain, prescriptions for Motrin (a non-narcotic pain medication) and Lortab (a narcotic pain medication), and instructions to follow up with her primary care provider or return immediately if symptoms worsened. Further review revealed the hand written signature of patient #30 on a line at the bottom of the form (page 2), dated 06/30/2010 and witnessed by a staff nurse at 1730.

Review of a Discharge Teaching Form revealed documentation by a staff nurse patient #30 was discharged at 1731.

Record review failed to reveal any documented evidence of the findings of a medical screening examination (MSE) performed by a qualified medical professional (DED physician 3) for patient #30 during her DED visit on 06/30/2010.

Interview on 11/18/2010 at 1230 with Administrative Management Staff and the Chief Medical Officer confirmed there was no available documented evidence in the DED record for patient #30 of the findings of the MSE performed by DED physician 3 on 06/30/2010.

Telephone interview on 11/18/2010 at 1323 with DED physician 3 revealed he was the attending physician working the "triage shift" at the hospital's main campus DED on 06/30/2010 when patient #30 presented with complaints of neck pain from a motor vehicle accident. Interview revealed he does not remember the patient. Interview revealed as the triage physician he evaluates and treats minor cases then discharges them from triage. Interview revealed he performs a MSE on each patient evaluated in triage. Interview revealed the MSE findings are documented in the DED record by writing a "quick note" or by dictation. Interview revealed the MSE findings are documented immediately after the MSE is performed or as soon as possible. Interview revealed at times when the DED is busy, charts are placed aside and documented on at the end of the shift. Interview revealed occasionally charts are accidently picked up before the physician has completed the documentation (MSE) in the chart. Interview revealed he was unaware the DED record dated 06/30/2010 for patient #30 did not reveal any documented evidence of the MSE findings. Interview revealed "Without the documentation it is hard to say what the findings were."

Based on policy review, medical record review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide stabilizing treatment within its capability and capacity for 1 of 1 sampled DED patients that was discharged with an emergency medical condition (#7).

The findings include:

A review of the hospital's policy "EMTALA Compliance, Including Patient Transfers (Emergency Medical Treatment and Labor Act)" (Reviewed 10/2008) revealed "A medical screening examination will be performed on any person presenting to the hospital who either personally, or for whom any person, requests emergency service or care to determine whether or not an emergency medical condition exists." The policy further revealed "Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Serious impairment to bodily function and serious dysfunction of any bodily organ or part." Documentation further revealed "If if has been determined by qualified medical personnel that an emergency medical condition exists: Treatment will be provided by the hospital, the emergency physician, and when medically necessary, by the on-call specialist physician, to relieve, eliminate or stabilize the emergency medical condition within the capabilities of the staff, ancillary services and facilities available to the hospital."

1. Closed dedicated emergency department (DED) medical record review on 11/17/2010 for patient #7 revealed, a 51 year old male who presented to hospital "A's " main campus DED on 10/16/2010 at 0428 via emergency services helicopter after being hit as pedestrian by another vehicle. The patient was triaged at the hospital's DED as a trauma patient with a documented primary evaluation conducted. Documentation revealed that the patient at triage had pain in his "Left lower leg and all over his body" with the pain rated as "6 of 10" with 10 being the most severe pain. The documentation of the patient's vital signs at the time of triage (0428) revealed that the patient's heart rate was "105" and blood pressure at 108/70. Documentation of the patient's pain levels revealed that the patient continued to report his pain level as "6 of 10" until 0615.

Documentation from the patient's medical record revealed the hospital's DED resident physician #1 examined the patient at 0451 on 10/16/2010. The documentation from the DED resident physician revealed that the patient was a "Pedestrian struck by car, complaint of Left Leg and Right Shoulder pain." Further documentation revealed that the patient was "Middle aged male possible MR (Mentally Retarded) versus ETOH (Alcohol) intoxication status post pedestrian versus car; complaint of right upper extremity pain, left lower extremity pain, Cat scan of head/cervical spine cat scan pending, vitals within normal limits, exam otherwise unremarkable. Will reassess after cat scan of head/cervical spine cat scan result- discharge home with strict return to emergency department." No further documentation was found from the DED physician resident #1.

Documentation from the patient's medical record further revealed that the patient was seen by DED physician resident #2 after a change of shift for the residents. The documentation revealed from resident #2 at 0722 "No complaint of pain, patient awake and *** (not legible) at baseline mental status, exam unchanged, negative CT scan. All questions from family, patient and group home representative." The documentation from the resident also revealed "will discharge to group home with pain medications. Follow up with primary medical doctor in 1-2 days. Plan reviewed with group home worker."

Documentation from the DED attending physician (no time documented) assigned to the patient revealed "Seen at bedside with Dr.___ (DED physician resident #1), he was struck by a car and has multiple abrasions. Right shoulder pain. He has Glasgow Coma Scale 15, chest clear, (not legible documentation), pelvis stable, He'll need X-ray, CT and reevaluation." No further documentation was found from the attending physician.

Documentation from the DED nursing staff for 10/16/2010 revealed at 0730 that the patient was "Resting quietly. No complaints, Family at bedside. Normal Saline infusing without problems." Documentation by the nursing staff at 0830 revealed, "Adaptors d/ced times 2, Abrasions dressed with sterile dressing with bacitracin (Antibiotic cream). Patient walked in room. Discharged with caregiver and family."

The review of the medical record for 10/16/2010 revealed that the patient was discharged from the hospital's DED at 0830. No documentation was found where the patient received any pain medications during the visit in the DED from 0425 through 0830. The review further revealed that the patient was given discharge diagnosis by the DED physicians as "Abrasions and Alcohol Abuse". The patient was documented as stable and discharged home according to the documentation.

Documentation review on 11/17/2010 of the patient's closed medical record from hospital "B's" DED for 10/16/2010 revealed that the patient presented to that hospital's DED at 1031 after leaving hospital "A" with a complaint of "family stating the patient was hit by a car after wondering away from group home." The family also reported that the patient had been airlifted to hospital "A" and the family was notified about 0430 (10/16/2010) this AM of patient arrival to hospital "A". Patient was discharged and family called PCP (Primary Care Provider) and was instructed to the ECC (No definition known)."

Documentation of the DED physician's report for 10/16/2010 at hospital "B" revealed that the patient had chief complaint of "Leg Pain." The documentation revealed that "hospital "A" evaluated and discharged the patient. The patient had spoken with his primary medical doctor because the patient is now refusing to walk and complaining of significant pain in his legs." The documentation from the physical examination of the DED physician at hospital "B" revealed that "the patient does have a significant hematoma to the left side of the face. The patient has significant abrasions to the left lateral knee, significant tenderness to the medial and lateral joint lines of the knee. Minimal left ankle tenderness over the lateral malleous. The patient had significant tenderness to the right elbow again, with multiple abrasions there." The documentation review revealed that the DED physician at hospital "B" ordered further radiological testing for the patient. Further documentation by the DED physician at hospital "B" revealed "Evaluation from __hospital "A" was radiology tests which were reevaluated here in the emergency department by myself. The patient had a CT head, which is read as no acute brain abnormality; CT cervical spine, showing no acute fracture. The patient had one view of the shoulder, right shoulder: No evidence of fracture. Pelvis: No fracture, dislocation, or subluxation, and a chest x-ray showing mild pulmonary congestion. In addition, here abdomen and pelvis were obtained showing no acute intra-abdominal injury. Right elbow x-ray showing a nondisplaced fracture through the right radial head, with associated joint effusion. Left knee showing minimally displaced fracture, posterior aspect of the left lateral femoral condyle." Documentation for treatment by the DED physician at hospital "B" revealed " The patient was put in a knee immobilizer on the left lower extremity. Arm was splinted with a sugar tong splint on the right arm. Orthopedics at ___ (hospital "B") was consulted, Dr. ___(orthopedic physician #1 on call hospital "B") who recommended transfer back to hospital "A" with multiple extremity fractures, status post auto-pedestrian. The Dr.___ feels that he should be followed by trauma. Hospital "A" was contacted. Transfer accepted by Dr.___ (Physician #2 at hospital "A")." The documentation revealed that the patient was discharged by transfer from hospital "B" to hospital "A" by emergency medical services transport. The diagnosis from hospital "B's" DED physician was documented as "Radial head fracture and Femoral condyle fracture." Documentation in the DED record at hospital "B" further revealed that the patient did receive pain medication "Morphine Sulfate 4 milligrams" and anti nausea medication "Zofran 4 milligrams" intravenously while a patient at the hospital.

Review on 11/17/2010 of the open medical record for patient #7 revealed that the patient presented to hospital "A's" DED again on 10/16/2010 at 1650 by emergency medical services after being transferred from hospital "B's" DED for further treatment and admission. The documentation from hospital "A's" triage nurse at 1711 revealed "This morning discharged from emergency department after evaluation, pedestrian struck by Motor Vehicle. Patient transferred from ___(hospital "B's") emergency department for evaluation of left femur fracture and right elbow fracture. Abdomen distended, denies pain." Documentation by the same registered nurse from triage documented that the patient's pain level was rated as "10 on scale of 1-10" in lower left leg with description as sudden, sharp and shooting" at 1702.

Review of the medical record's "Orthopaedic Service History and Physical" for 10/16/2010 at 2200 revealed the "patient has effusion noted on left knee. Left lower extremity tender knee and ankle. Right elbow-nondisplaced radial fracture, left femoral condyle fracture." The orthopaedic history and physical diagnosis was documented by the physician as "Right non-displaced radial head fracture and left lateral femoral condyle fracture." The documentation of the plan of care by the orthopaedic physician at hospital "A" revealed "Admit patient, plan for ORIF (open reduction and internal fixation surgery) left femoral condyle fracture, obtain consents, right arm sling for comfort, non weight bearing, Medicare clearance." The documentation revealed that patient #7 was admitted (10/16/2010) to the hospital and discharged during the investigation on 11/18/2010 (34 days later).

An interview on 11/17/2010 at 1248 with the DED physician resident #1 from hospital "A" revealed that she remembered the patient presenting to the DED by helicopter with reports of being hit by a car. The interview revealed that the DED physician resident was working the shift of 1900 (10/15/2010) through 0500 (10/16/2010) and was the first physician to examine the patient. The interview revealed that at triage the patient had primary trauma workup conducted. "I did not know the underlying conditions of the patient. I do not remember deformity of the patient's knee. I am familiar with the patient's outcome when he left our emergency department." The interview revealed that the DED physician resident signed off around 0500 and turned the case over to another DED physician resident. The interview also revealed that the attending physician in the DED does examine patients along with the residents. The DED physician resident revealed that she treated the patient for the symptoms that he had at the time of the presentation. The interview also revealed "I would have gotten same tests, maybe if there longer or a change in clinical status, I would have gotten other testing to discover the fractures. The patient did not receive any medications for pain that I remember."

An interview on 11/17/2010 at 1540 with the DED physician resident #2 from hospital "A" revealed that he started shift on 10/16/2010 at 0600 and did remember patient #7. "I took over for DED resident physician #1 and took over the care for the patient. I remember the patient seen after helicopter trauma evaluation. A survey was done of the patient, imaging done for stabilization. I remember visiting with family and some people from the group home in the patient's room. I also remember the patient having a MR (mental retardation) history. It was difficult to determine the patient's pain level. I talked with mother or someone with the patient denying pain. I did not pick up on the knee tenderness. I missed it. The nurse got the patient to ambulate on our orders and I did not actually see the patient ambulate. I do not remember examining the patient. I missed the tenderness in the knee that the fracture was at. That would have triggered the x-rays." The interview revealed that the DED physician resident did know that the patient had fractures discovered after discharge from the hospital. The interview also revealed that the DED physician resident #2 did not discuss the patient's condition with any attending physician in the DED before discharge. The interview also revealed that the patient did not receive any medications while in the DED, only a prescription for pain medications at the time of discharge.

An interview on 11/18/2010 at 1115 with the DED attending physician for patient #7 revealed that the physician did see the patient at bedside with the DED physician resident #1. "The patient was a trauma case. After trauma he went to different areas in the emergency department. CT's were negative and he went home. I would do same process if it happened again. Care would be the same. I feel it was appropriate medical screening and stability for the patient. As a rule for those traumas, "If they can walk, they can go." The interview also revealed that a patient being able to walk would not 100% rule out a fracture in a patient." The interview also revealed that the attending physician did not see the patient walk, it was the nurse. The patient also was discharged after the DED attending physician left the shift at 0700. The interview also revealed that no examination for tenderness was done that he knew about for the patient. The interview further revealed the physician asked why the patient would be checked for "tenderness."

An interview on 11/18/2010 at 0934 with the DED nurse assigned to patient #7's discharge revealed "The physician resident (#2) wanted the patient to get up and walk. A male caregiver was with him to assist from the group home. One of our technicians helped him to dress. Patient wanted to use the bathroom. He had to be reinforced due to his MR. No expression of pain was noted. The patient did not complain of pain that I can remember. I told the physician that he walked to the bathroom and he was discharged by wheelchair. I do not remember how he walked. He was mentally handicapped so he had slow walk anyhow. I do not remember the patient's receiving any pain medications in the emergency department.

Consequently, patient #7 presented to hospital "A's" DED by helicopter after being struck by a vehicle while laying in the road on 10/16/2010. The patient was examined by two (2) DED physician residents and an attending DED physician at hospital "A". The patient complained of leg pain and overall pain and had imaging in the trauma protocol done. No imaging tests were done for the patient's leg or elbow. The patient was discharged from hospital "A's" DED without pain medications being administered or other imagining tests for his leg and elbow. The interviews with hospital "A's" DED resident physicians and attending physicians revealed that all three physicians failed to examine the patient's documented tenderness in his knee area. The patient was taken to another hospital's DED (hospital "B") after leaving hospital "A" and was diagnosed as having left leg femur condyle fracture and right elbow fracture. Consultation from the hospital "B's" oncall orthopaedic physician recommended that the patient be transferred back to hospital "A" due to the extend of the fractures and injuries with trauma services needed. The patient was transferred back to hospital "A's" DED and admitted under the orthopaedic services for the needed surgical procedures. The patient was admitted to hospital "A" from 10/16/2010 through 11/18/2010 (34 days).

Reference NC 00069050