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Based on record review and interview, the facility's emergency department physician failed to complete a medical screening for Patient #1's condition before being discharged home.

Cross refer to Tag 2406

Based on record review and interview, the facility's emergency department physician failed to complete a medical screening exam for Patient #1's condition before being discharged home.

This deficient practice had the likelihood to cause persistent pain, altered gait, long-term disability. There was a likelihood of "Compartment syndrome" (a condition where increased pressure within a muscle compartment (surrounded by fascia) restricts blood flow, leading to tissue damage) which could have occurred due to the calcaneus fracture.

Findings include:

A review of the triage record revealed that Registered Nurse #25 documented the following:

"patient in wheelchair to room, patient alert and oriented x 4, neighbor in waiting room. Patient reports he was stepping down the ladder of his deer stand this evening and slipped on the ladder rolled the right ankle and patient crawled to the 4-wheeler."

Temp 98.7 Pulse 78 respiratory rate 18 Blood Pressure 140/91 Oxygen 98% on room air.


Patient event history:
1957 (7:57 PM) Reception
1957 (7:57 PM) Patient registered
2035 (8:35 PM) Triage
2036 (8:36 PM) Patient in room
2035 (8:35 PM) Provider disposition
0003 (12:03 AM) Patient discharged

Patient #1 was seen by the Nurse Practitioner #10 and Physician #11.

Nurse Practitioner #10 signed off at 10:00 PM and Physician #11 took over the care of Patient #1.

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

"History/Physical
Document Date and Time Nov 2, 2024, at 21:10 (9:10 PM)

Time Seen by Provider: 20:00
General: Chief Complaint: Extremity injury

Complaint Description
45-year-old male presents with complaint of pain and swelling to his right ankle after he twisted his ankle while coming off the ladder of his deer stand just prior to arrival today.

Vital signs: 11/2/2024 2035 (8:35 PM)
Temp 98.7 Pulse 78 respiratory rate 18, Blood pressure 140/91 oxygen 98% on room air

Procedures
Splinting/Fracture/Dislocation
Time: 22:02 (10:02 PM)
Splint: Crutches, Short-leg
Applied by: Nurse
Exam Post Splint Application: Neuro intact, Vascular intact, Alignment good Post Procedure Status: Patient tolerated procedure well.

Time: 22:02 (10:02 PM)
Interval Plan
Left lower extremity is warm and well-perfuse without neuromuscular deficit

Medical Decision Making
Comment:
Chief complaint: 45-year-old male presents with complaint of pain and swelling to his right ankle after he twisted his ankle while coming off the ladder of his deer stand just prior to arrival today.

Problems:
Differential diagnoses include but not limited to: Fracture, dislocation, contusion, sprain, strain
External Notes Reviewed: Nurses notes and vitals reviewed
History Obtained others: History obtained from the patient.
Tests and Images ordered and reviewed by me: X-ray right ankle is pending
ED course: hydrocarbon 10/325 mg, Oran 4 mg P.O., Toradol 60 mg IM given in ER, posterior short leg splint and crutches with good improvement.

Clinical impression/disposition/follow-up: Right ankle Sprain pending radiologist report. Patient is stable for discharge home with outpatient treatment and follow-up

Discussions regarding hospitalization, escalation of care, or emergency surgery: Not applicable Discussions regarding de-escalation of care: I discussed all test results and treatment plan with patient. I instructed patient to follow-up with Orthopedic specialist within 72 hours. I discussed reasons to return to emergency room.
Patient is comfortable, no distress. Hemodynamically stable. Right lower extremity is warm and well-perfused without neurovascular deficit."

Further review of the medical record revealed no assessment for a spinal injury due to the height of the fall from the deer stand (8 feet). The foot was not examined for injury. Patient #1 complained of pain in the ankle and radiating down to the foot. Foot injuries account for 15-25% of ankle injuries due to the type of fall injury that occurred with an 8-foot fall. The physicians documentation referred to the nurse's triage note.

A review of the X-rays indicated there were no foot or spinal X-rays or scans ordered.

An interview with Physician #11 on 12/10/2025 at 2:00 PM acknowledged the calcaneus fracture had been missed by the radiologist.