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Based on document review, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Medical record review revealed Patient #1 presented to Hospital #1's ED via ambulance on 5/11/2024 with complaints of a fall resulting in pain in the left knee and right shoulder. Patient #1 rated her pain a level of 7 on a scale of 0 - 10. Patient #1 reported being treated for a Urinary Tract Infection but had not started on antibiotics yet. The Patient further reported generalized weakness, intermittent fever, and some nausea. Patient #1 was seen by ED Provider #1 who documented Patient #1 had tenderness in her left knee upon palpation (part of a medical exam that involves feeling or pressing on specific areas of the body to detect abnormalities).

The Patient's white blood cell count (WBC) was 10.3 with a reference range of 5.0 - 10.0, red blood cell count (RBC) was 3.65 with a reference range of 4.1 - 5.4, hemoglobin (Hgb) was 9.1 with a reference range of 12.0 - 16.9, hematocrit (Hct) was 29.9 with a reference range of 37.0 - 47.0, Potassium (K+) was 3.4 with a reference range of 3.5 - 5.0, Troponin was 7 with a reference range of less than (<) 5, and Mag was 1.7 with a reference range of 1.8 - 2.4.

Patient #1 was deemed stable and was discharged home via medical transport at 5:30 PM with instructions to rest, elevate and ice her left knee, take non-steroidal anti-inflammatories as needed for pain, and to follow up with her Primary Care Physician for a possible evaluation for rehabilitation services. The Patient's final diagnoses included Generalized Weakness and Contusion of Left knee.

There was no documentation Patient #1 was treated for her pain and no documentation the Patient's pain level was reassessed prior to her discharge from the hospital.

Patient #1 returned to the Hospital #1's ED via ambulance 3 days later on 5/14/2024 with complaints of generalized weakness. The Patient was seen by ED Provider #2. The Provider indicated he was familiar with the Patient as she was seen 3 days earlier by ED Provider #1 while he was also on-duty. The Provider documented Patient #1 stated she had been feeling increasingly weak over the last several days. ED Provider #2 documented, " Was here 3 days ago workup at that time was largely unremarkable. She is back today with very similar complaints. Will repeat in and out catheterization repeat x-ray of chest and blood work did express to the patient that she has generalized deconditioning, and decline may not be able to find acute etiology (manner of causation of a disease or condition) to explain her complaints with [which] she thinks that there is..."

The Patient's WBC had increased to 12.8, RBC had increased to 3.68, Hgb had decreased to 9.2, Hct had decreased to 28.6, Mag level was stable at 1.7, and K+ had decreased to 3.1.

The CT scan results showed, "1. No acute findings in the chest, abdomen, or pelvis. 2. Nonspecific incompletely visualized cystic collection seen within the deep musculature of the left upper thigh. Etiology for this is indeterminate. Consider MRI [Magnetic resonance imaging]. Differential would include abscess. Correlate with clinical history or pain to this area. 3. 1 cm [centimeter] ovoid hyperdensity within the midpole the right kidney. this could reflect a nonobstructing stone."

ED Provider #2 documented, "I did a CT of the chest abdomen and pelvis it is unremarkable she does not have urinary tract infection she is not dehydrated. She has a component of deconditioning and arthritis no indication for admission to the hospital which I explained to her at length at the bedside. She is stable for discharge home otherwise..."

Patient #1 was discharged home via medical transport on 5/14/2024 at 9:53 PM with instructions that included, "You may benefit from rehab facility. Your workup in the ER [Emergency Room] consisting of blood work urine and CT of the chest abdomen and pelvis were all unremarkable other than a component mild-to-moderate anemia. Follow-up with your primary care provider for discussion of rehab admission."

The Patient's final diagnoses included Physical Deconditioning, Arthritis, and Anemia.

There was no documentation ED Provider #2 acknowledged the CT findings of the "nonspecific incompletely visualized cystic collection seen within the deep musculature of the left upper thigh...Differential would include abscess. Correlate with clinical history or pain to this area." There was no documentation ED Provider #2 assessed or examined Patient #1's thigh area for the presence of a possible abscess or pain.

2. Patient #1 presented to Hospital #2's ED via ambulance 2 days later on 5/16/2024 with complaints of dysuria, hematuria, suprapubic and back pain radiating down her legs. The Patient reported intermitted fever and chills. Patient #1 was seen by ED Provider #2 who ordered a CBC, CMP, UA, Lactic Acid, chest x-ray, and CT scans of the abdomen, pelvis, left femur, and left knee.

The Patient's WBC had increased to 14.0, RBC had increased to 3.85, Hgb had increased to 9.3, Hct had increased to 30.6, K+ level was stable at 3.1, the Lactic Acid level was 1.3 with a reference range of 0.7 - 2.1, and the C-reactive Protein (CRP) was 19.5 with a reference range of 0.0 - 0.9. The urine specimen was dark yellow in color and had 1+ bacteria, 1+ epithelial cells, and small bilirubin present.

ED Provider #3 at Hospital #2 documented, "...Brief Synopsis 72-year-old female who presents for hematuria, dysuria, lower abdominal and lower back pain. CMP stable however CBC with leukocytosis 14 she also had elevated CRP [C-reactive protein - a protein produced by the liver in response to inflammation) of 19.5. Pt given cefepime [antibiotic] and fluids for empiric sepsis...presently was not suggestive of urinary tract infection. CT abdomen and pelvis ordered and showed fluid collection within...this musculature. CT of the left thigh with contrast ordered for further elucidation and showed multiloculated fluid collection anterior to the femur it appears to extend from the knee joint. Hospitalist called for. Surgery consulted and stated to consult orthopedics given involvement of the knee joint. Orthopedics consulted and advised placing IR [Interventional Radiology] consult for aspirate, culture and drain. IR consulted and advised placing CT abscess drainage order. Pt admitted in stable condition..."

Review of the Discharge Summary revealed, Patient #1 underwent surgical debridement of the left knee abscess on 5/17/2024 with cultures testing positive for Staph aureus (bacteria). The Patient was taken back to surgery on 5/19/2024 for another debridement and surgical revision of the left knee and irrigation of the left thigh. Patient #1 suffered post-operative complications and ultimately expired in the hospital on 5/22/2024. Patient #1's discharge diagnoses included Persistent acute toxic metabolic encephalopathy secondary to sepsis, Septic shock, Acute hypercarbic respiratory failure, Acute kidney injury, Lactic acidosis, Severe sepsis with septic shock, Left anterior thigh proximal abscess, Left temporal intraparenchymal hemorrhage, Subarachnoid hemorrhage along the insular cortex in the left frontal lobe, Tachycardia [rapid heart rate], Back pain, Hematuria, Lower leg pain-swelling, and Suprapubic abdominal pain.

Cross Refer to A-2406.

Based on document review, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and on-going medical screening examination (MSE), monitoring and treatment for 1 of 20 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital document, "Rules and Regulations of the Medical Staff of [Hospital #1]" revealed, "...A medical doctor shall be dedicated to providing competent medical service with compassion and respect for human dignity...When an individual presents to the emergency department requesting examination or treatment of a medical condition, the medical screening examination is based on the individual's presenting complaint..."

Review of the hospital policy, "Evaluation and Transfer of Patients with Emergency Medical Conditions/EMTALA [Emergency Medical Treatment and Labor Act] Including Pregnancy with Contractions" revised 11/2024 revealed, "...Terms...Emergency Medical Condition...Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in...Placing health of individual...in serious jeopardy...Serious impairment to bodily functions, or ...Serious dysfunction of any bodily organ or part...Medical Screening...Persons requesting examination or treatment for medical conditions are provided an appropriate medical screening examination to determine whether or not they have emergency medical conditions...The initial medical screening and stabilizing treatment includes the use of necessary ancillary services routinely available at [Hospital #1]...If patient is determined to have an emergency medical condition as defined above, further medical examination and treatment may be needed to stabilize the patient. The patient is provided, within capabilities of the staff and facilities available at hospital, further medical examination and treatment as required to stabilize the medical condition or transfer the patient..."

Review of the hospital policy, "Pain Management Guidelines" revised 3/2024 revealed, "...Pain may be physiological, emotional, stress, or spiritual and the effectiveness of pain management is measured and reported. Guidelines: 1. Pain is assessed and managed according to the needs of the patients, current clinical condition, past medical history, pain management goal, and current evidence based practice. 2. Patients are screened for pain in the emergency department and at time of admission. 3. A comprehensive pain assessment is performed at admission...and upon new complaint of pain and includes but is not limited to...Initial Pain score...Pain goal...Pain type...Pain location...4. Pain interventions are provided and documented, and can include nonpharmacologic, pharmacologic, or a combination of approaches. 5. Pain reassessments are completed and documented approximately 1 - 2 hours after an intervention is provided and include...Current pain score...Response to pain intervention 6. The patient is involved in developing realistic pain management expectations and goals and understands the objectives of pain relief, reductions, and treatment options...13. Pharmacologic pain management orders included levels of pain (i.e. mild, moderate, severe), using the following categories...1 - 3 Mild Pain...4 - 6 Moderate Pain...7 - 10 Severe Pain..."

2. Review of the Emergency Medical Service (EMS) report from EMS Service #1 dated 5/11/2024 revealed the ambulance unit was dispatched to Patient #1's residence at 11:15 AM, was on the scene with Patient #1 at 11:33 AM and, "...met patient [Patient #1] inside. Upon patient contact patient was found lying in the right lateral recumbent position (when a person lies on their right side) oriented with the top of her facing the door. Patient presented AOOx4 [awake, alert, oriented times 4 (person, place date, time, situation)] and in obvious pain. ABC's [airway, breathing, circulation] intact. Patient stated she was using her roll walker when it suddenly stopped causing her to fall. Patient stated she tried to catch herself with her left leg and hurt it causing her to fall on her right side injuring her right shoulder. Patient denied LOC [loss of consciousness] or any neck or spinal pain. Patient's right shoulder hurt upon deep palpation and movement. Patient was sat upright in the floor to be further assessed. Patient has had double knee surgery and takes Tremedol [Tramadol - medication used to treat moderate to severe pain] for chronic pain. Patient stated she is normally able to get around with assistance from her roll walker but has had trouble putting weight on her legs. Due to patient being obese it was difficult to tell if swelling was present. PMS [pulse, motor, sensory] was still intact with pain upon movement. Patients [patient] had a pillow placed between her legs for stabilization with both legs bound with triangle bandages (bandages used to make ties to secure other kinds of splints in place). Patient was then direct lifted and placed onto the stretcher and secured...loaded into the ambulance. Patient vitals taken...IV [intravenous] Access failed x 1...4 lead showed a sinus rhythm of 75 bpm [beats per minute]...Head to toe found no other injuries with PMS intact in all extremities...Arrived at [Hospital #1]...transfer of care given to ER [emergency room]..."

Review of Hospital #1's Emergency Department (ED) log revealed Patient #1 presented via ambulance on 5/11/2024 at 12:37 PM with chief complaint of "Fall; shoulder Pain; Knee Pain."

Medical record review revealed Patient #1 presented to Hospital #1's ED via ambulance on 5/11/2024 at 12:37 PM. A triage assessment was completed by Registered Nurse (RN) #1 at 12:38 PM who documented, "Patient arrives from home via ems [named EMS Service #1] for fall at home...complains of right shoulder and left knee pain.." Patient #1 rated her pain a level 7 on a scale of 0 - 10. Patient #1 was assigned an ESI level 3 and placed in a room in the ED.

A full nursing assessment was completed by Registered Nurse (RN) #2 at 12:42 PM who documented Patient #1 was at high risk for falls, complained of pain in the left knee rating pain a level of 7 on a scale of 0 - 10, and the Patient had peripheral edema (swelling) in her left lower leg.

Patient #1 was seen at 12:47 PM by ED Provider #1 who documented, "72 year-old female with past medical history of hypothyroidism [low thyroid hormone], hypercholesterolemia [high cholesterol] and hypertension [high blood pressure] presents after falling this morning. She is complaining of left knee and right shoulder pain. She states she has been sick for several days with intermittent fever, weakness and nausea. She states that she was seen by her PCP [primary care physician] who advised her to come to the emergency room a few days ago as her potassium level was low. states today she is just so weak she is unable to stand. She states she is supposed to be taking medications for urinary tract infection, but her medication has not come in the mail yet...Review of systems...Musculoskeletal: Positive for arthralgias [joint pain] and myalgias [muscle pain]...Physical Exam...not in acute distress...She is obese...Musculoskeletal: General: No swelling or tenderness. Normal range of motion...Comments: Tenderness with palpation [a medical examination technique that involves feeling or pressing on specific areas of the body to detect abnormalities] to anterior left knee..."

The Patient's white blood cell count (WBC - blood cells that fight infection) was 10.3 with a reference range of 5.0 - 10.0, red blood cell count (RBC) was 3.65 with a reference range of 4.1 - 5.4, hemoglobin (Hgb - a protein found in the red blood cells that transport oxygen throughout the body) was 9.1 with a reference range of 12.0 - 16.9, hematocrit (Hct - percentage of red blood cells in the total volume of blood) was 29.9 with a reference range of 37.0 - 47.0, Potassium (K+) was 3.4 with a reference range of 3.5 - 5.0, Troponin was 7 with a reference range of less than (<) 5, and Mag [magnesium] was 1.7 with a reference range of 1.8 - 2.4.

The catheterized urine specimen revealed dark yellow urine with trace ketones (acids the body makes when it is using fat instead of glucose for energy); all other results were negative.

Patient #1 was deemed stable and was discharged home via medical transport at 5:30 PM with instructions to rest, elevate and ice her left knee, take non-steroidal anti-inflammatory medications as needed for pain, and to follow up with her Primary Care Physician (PCP) for a possible evaluation for rehabilitation services. The Patient's final diagnoses included Generalized Weakness and Contusion of Left knee.

There was no documentation Patient #1 was treated for her pain and no documentation the Patient's pain level was reassessed prior to her discharge from the hospital.

Review of the EMS report from EMS Service #1 dated 5/11/2024 revealed the ambulance unit was dispatched to Hospital #1 at 5:23 PM to transport Patient #1 back to her residence.

Review of the EMS report from EMS Service #1 dated 5/14/2024 revealed the ambulance unit was dispatched to Patient #1's residence at 4:38 PM and was on the scene with Patient #1 at 4:57 PM. The report further revealed, "...Pt states she does not feel well. pt states this issue is X [times] 3 days and she has been vomiting. pt also report large amounts of blood in urine and generalized weakness...Pt reports that she was in the hospital 3 days ago [5/11/2024] prior to this contact for this complaint. Pt reports that she was discharged home with no further instructions. Pt states that she began having large amounts of blood in her urine and she has felt weaker with each day. Home Health nurse confirms blood in urine and reports Pt has had a mild fever for 2 days...Breathing unlabored and no signs of injury...Pt has a low grade fever [there was no documentation in the EMS report of the temperature taken] and EMS confirmed blood in urine in bedside toilet...Pt was very weak and unsteady on her feet...IV [intravenous] access obtained...administered normal saline via IV at TKO [to keep open] for decreased BP and sepsis [a complication of infection] protocol...administered oxygen via BNC [by nasal cannula] at 2 LPM [liters per minute] due to low SPO2 [oxygen saturation of peripheral oxygen] Pt SPO2 reassessed and noted as improved...Pt was assisted to transfer to EMS stretcher and placed in position of comfort...Pt monitored closely en route and Pt transported without incident.

Review of Hospital #1's ED log revealed Patient #1 presented via ambulance on 5/14/2024 at 5:44 PM with chief complaint of "Generalized Weakness."

Medical record eview revealed Patient #1 presented to Hospital #1's ED via ambulance on 5/14/2024 at 5:44 PM. A triage assessment was completed by RN #3 at 5:44 PM who documented, "Pt has been sick since Saturday [5/11/2024]. Home health noticed a lot of blood in urine." Patient #1 rated her pain a level 7 on a scale of 0 - 10. Patient #1 was assigned an ESI level 3 and placed in a room in the ED.

Patient #1 was seen at 5:55 PM by ED Provider #2 who documented, "Patient presents with complaint fatigue feeling poorly she said she has felt poorly for the past several days. This patient was actually seen here in the emergency room 3 days ago when I was here. I did not see her but then [the] mid-level provider [ED Provider #1] did. We have discussed this patient at length she had had [sic] a cath [catheterized] urine that was unremarkable. she had had [sic] multiple x-rays done of her chest back shoulder and knee all of which were unremarkable for any acute fracture...Weakness - Generalized: Severity: Severe...Progression: Worsening...Associated symptoms: arthralgias, cough, dysuria [painful urination], myalgias and shortness of breath...Physical Exam...She is not in acute distress...She is obese...Abdominal...There is distension...Very obese abdomen. Hard to perform any meaningful examination. Genitourinary...There is diffuse redness and excoriation noted of the vaginal area externally and internally Musculoskeletal: Cervical back: Normal range of motion. Lumbar back: Tenderness present. No bony tenderness. Decreased range of motion...Medical Decision Making Very obese female with complaints of chronic debilitation and lack of energy. Was here [Hospital #1] 3 days ago workup at that time was largely unremarkable. She is back today with very similar complaints. Will repeat in and out catheterization repeat x-ray of chest and blood work did express to the patient that she has generalized deconditioning [a state of physical weakness, fatigue, and reduced functional capacity that occurs due to prolonged inactivity or a sedentary lifestyle], and decline may not be able to find acute etiology [manner of causation of a disease or condition] to explain her complaints with [which] she thinks that there is..."

At 6:57 PM, RN #4 documented, "Pt c/o [complains of] headache. Reported to [ED Provider #2]".

At 7:16 PM a urinary catheter was inserted with an output of 200 milliliters (ml) of amber colored urine collected. The catheter was attached to a drainage bag and left in place due to "Urinary retention/obstruction." RN #4 documented the insertion "Site Assessment: Red; Painful."

At 7:27 PM, ED Provider #2 ordered a one-time dose of hydrocodone-acetaminophen (narcotic pain medication used to treat moderate to severe pain) 7.5-325 mg tablet by mouth for pain. The medication was given at 7:30 PM and Patient #1 rated her pain a level of 5 on a scale of 0 - 10.

Results of Patient #1's test revealed the WBC had increased to 12.8, RBC had increased to 3.68, Hgb had decreased to 9.2, Hct had decreased to 28.6, Mag level was stable at 1.7, and K+ had decreased to 3.1. The catheterized urine specimen was dark orange in color and had trace ketones and moderate bilirubin (a yellow pigment produced when red blood cells break down) present. The CT scan results showed, "1. No acute findings in the chest, abdomen, or pelvis. 2. Nonspecific incompletely visualized cystic collection [fluid-filled sac or lesion that can develop in many parts of the body] seen within the deep musculature of the left upper thigh. Etiology for this is indeterminates. Consider MRI [Magnetic resonance imaging - a non-invasive procedure that uses radio waves and magnets to create detailed images of the body's internal structures]. Differential would include abscess. Correlate with clinical history or pain to this area. 3. 1 cm [centimeter] ovoid hyperdensity within the midpole the right kidney. this could reflect a nonobstructing stone."

ED Provider #2 documented, "Extensive workup was done in the emergency department. I did a CT of the chest abdomen and pelvis it is unremarkable she does not have urinary tract infection she is not dehydrated. She has a component of deconditioning and arthritis no indication for admission to the hospital which I explained to her at length at the bedside. She is stable for discharge home otherwise. Patient was very disappointed that she was being discharged but as I explained to her repeatedly I have no indication for hospital admission..."

Patient #1 was discharged home via EMS at 9:53 PM with instructions that included, "You may benefit from rehab [rehabilitation] facility. Your workup in the ER consisting of blood work urine and CT of the chest abdomen and pelvis were all unremarkable other than a component mild-to-moderate anemia. Follow-up with your primary care provider for discussion of rehab admission." The Patient's final diagnoses included Physical Deconditioning, Arthritis, and Anemia.

There was no documentation ED Provider #2 acknowledged the CT findings of the "nonspecific incompletely visualized cystic collection seen within the deep musculature of the left upper thigh...Differential would include abscess. Correlate with clinical history or pain to this area." There was no documentation ED Provider #2 assessed or examined Patient #1's thigh area for the presence of a possible abscess or pain.

Review of the EMS report from EMS Service #1 dated 5/14/2024 revealed the ambulance unit was dispatched to Hospital #1 at 9:32 PM to transport Patient #1 back to her residence.

3. On 5/16/2024 at 4:40 PM, EMS was dispatched to Patient #1's residence, was on the scene with Patient #1 at 5:00 PM and IV access was established and "Due to dehydration...hung a bag of Normal Saline at TKO ...Patient requested to be transported to [Hospital #2]... As patient was presenting with possible sepsis...made the decision to transport to [Hospital #2]...transported to the hospital.

Medical record review revealed Patient #1 presented to Hospital #2's ED via ambulance on 5/16/2024 at 6:57 PM with chief complaint of "r/o [rule out] sepsis."

Patient #1 was seen at 7:40 PM by ED Provider #3 who documented, "...female with history of hypertension, hypothyroidism, hyperlipidemia who presents for urinary symptoms. She complains of dysuria [pain with urination] and hematuria [bloody urine] as well as suprapubic [the area above the pubic bone, which is located in the lower abdomen] and low back pain with radiation down the legs. She endorses some subjective fever and chills. Reports on Monday started antibiotic however does not recall the name..."

Patient #1's test results revealed the WBC had increased to 14.0 (normal is 4.5 -11), RBC had increased to 3.85 (normal is 4.2 - 5.4 in women), Hgb had increased to 9.3 (normal is 12.0-15.5 in women), Hct had increased to 30.6 (36-48% in women), K+ level was stable at 3.1 (normal 3.5 - 5.2), the Lactic Acid level was 1.3 (with a reference range of 0.7 - 2.1), and the C-reactive Protein (CRP - a protein produced by the liver in response to inflammation) was 19.5 with a reference range of 0.0 - 0.9. The urine specimen was dark yellow in color and had 1+ bacteria, 1+ epithelial cells, and small bilirubin present.

ED Provider #3 at Hospital #2 documented, "...Brief Synopsis 72-year-old female who presents for hematuria, dysuria, lower abdominal and lower back pain. CMP stable however CBC with leukocytosis (a high white blood cell count over 10) at 14 and an elevated CRP of 19.5. Pt given cefepime [antibiotic] and fluids for empiric sepsis...presently was not suggestive of urinary tract infection. CT abdomen and pelvis ordered and showed fluid collection within...this musculature. CT of the left thigh with contrast ordered for further elucidation and showed multiloculated [having or made up of multiple small compartments or cavities] fluid collection anterior to the femur it appears to extend from the knee joint. Hospitalist called for. Surgery consulted and stated to consult orthopedics given involvement of the knee joint. Orthopedics consulted and advised placing IR [Interventional Radiology] consult for aspirate, culture and drain. IR consulted and advised placing CT abscess drainage order. Pt admitted to Hospital #2 in stable condition..."

Patient #1's discharge diagnoses included, Persistent acute toxic metabolic encephalopathy secondary to sepsis, Septic shock, Acute hypercarbic respiratory failure, Acute kidney injury, Lactic acidosis, Severe sepsis with septic shock, Left anterior thigh proximal abscess, Left temporal intraparenchymal hemorrhage, Subarachnoid hemorrhage along the insular cortex in the left frontal lobe, Tachycardia [rapid heart rate], Back pain, Hematuria, Lower leg pain-swelling, and Suprapubic abdominal pain.

4. During a telephone interview on 3/4/2025 at 12:13 PM, ED Provider #1 stated she did not recall Patient #1. The Provider was read her Provider note, then stated, "I don't remember the Patient at all. Not a hospitalization criteria. No choice but to discharge her home. Sounds like a negative work-up." ED Provider #1 was asked if she normally visualized patient's extremities when she palpated them. The Provider stated, "a knee exam I'm generally checking for stability and wouldn't necessarily undress them."

During a telephone interview on 3/4/2025 at 12:45 PM, the Medical Director for ED Provider #1 reviewed Patient #1's ED medical records from Hospital #1. The Medical Director was asked if there was anything significant in the diagnostic studies that were completed. The Medical Director stated the Patient's WBC increased from the first visit to the second visit, but the increase was not real significant, "I probably wouldn't get real excited about it." The Medical Director was asked if the CT findings showing the cystic collection of fluid in the Patient's left thigh should have been addressed. The Medical Director stated, "It would definitely make me go look at her [Patient #1] leg and palpate for tenderness. I would have done a better exam on that. I don't see that he documented that. I can't speak to whether he did it or not, but he didn't document it."

During a telephone interview on 3/4/2025 at 4:36 PM, the Director of Claims for ED Provider #1 stated, "We don't typically allow our clinicians to speak directly with the State [State survey agency]. We assign legal counsel to protect our clinicians when potential lawsuit or family prompted complaints come in." The Director continued and stated ED Provider #2 would not be available for interview at this time.