HospitalInspections.org

Based on policy review, medical record reviews, and staff and physician interviews, the hospital failed to:

1. Ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 5 sampled patients with a chief complaint of fall, (Patient #3).

2. Ensure stabilization of a patient with an emergency medical condition for 1 of 5 sampled patients with a chief complaint of fall, (Patient #3).

Findings include:

Cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406
Cross refer to 489.24 (d)(1-3), Stabilizing Treatment - Tag A2407

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 5 patients with a chief complaint of fall (Patient #3).

The findings included:

Review on 12/04/2019 of a policy titled "Emergency Medical Screening" last reviewed 10/05/2016 revealed, " ...The following policy is designed to ensure that (Hospital A Named) provides emergency medical screening examinations to any individual for whom an exam or treatment is requested in compliance with the Emergency Medical Treatment and Active Labor Act ... This federal law requires that any such individuals presenting to any (Hospital A Named) location receive a medical screening examination by personnel who are qualified to provide such screenings by virtue of their education, training, credentials, and experience ... All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary test, ancillary services, and/or on-call specialists ..."

Review of the closed Dedicated Emergency Department (DED) medical record for Patient #3 (Visit #1) revealed a 79 -year-old male that presented to the DED via EMS on 10/20/2019 at 0328 with a chief complaint of fall and left lower leg pain. Review of the triage nursing notes documented at 0328 revealed "Pt c/o (complaint of) left lower leg pain after a fall tonight." Review of the triage vital signs at 0328 revealed T (temperature) 98.8, P (pulse) 106, RR (respiratory rate) 16, BP (blood pressure) 117/69, O2 (oxygen) 96% on room air. Review revealed a pain assessment of 10 out of 10 (pain scale where 0 is no pain and 10 is the worst pain) with no documented location and he was triaged as a level 4. Review of a nursing pain assessment at 0334 revealed Patient #3 had 6/10 pain in the left knee. Review of the provider notes at 0338 by Medical Doctor (MD) #3 revealed " ...Seventy-nine year male presents complaint of left lower leg pain. Context is patient sustained a fall just prior to arrival. His wife called EMS they initially refused transport but he patient was concerned and wanted to know if he had a fracture or not. He states the pain is located only to left lower leg does not hurt to left hip or left knee or left foot. Pain is of mild intensity, worse with palpation or movement ...Review of Systems ...Musculoskeletal: extremity pain, no extremity swelling ...Findings ...Musculoskeletal: head/face atraumatic, tenderness-Left lower leg ...Test Results: Results: reviewed & interpreted by me to support final diagnosis Diagnostic Results: Tibia/Fibula X-ray 10/20/19 0348 IMPRESSION: No acute ossesous abnormality ...Medical Decision Making ...79-year-old male presents with complaint of left lower leg pain. X-ray shows no fracture. Patient has no pain to the hip. No bleeding. No other injuries on exam. He is at his baseline with functional status. Will discharge home with instructions ..." Review revealed Patient #3 received 1,000 mg of Tylenol PO (by mouth) at 0445 and had a pain score of 8/10 documented as " ...Pain location: rle (right lower extremity) ..." Review revealed Patient #3 had a tibia and fibula x-ray signed at 0421 by MD #4 which stated " ...FINDINGS: There is not evidence of fracture or dislocation. Bones appear osteopenic ..." Review revealed Patient #3 was not ambulated prior to discharge. Review revealed Patient #3 was discharged home via wheelchair with his family at 0505.

Review of the closed DED medical record on 12/03/2019 for Patient #3 (Visit #2) revealed Patient #3 returned to the DED on 10/22/2019 at 1136 via EMS with a chief complaint of leg pain. Review of the triage nursing notes documented at 1158 revealed " ...pt complaining of bilateral leg pain from a fall that took place on Saturday. Pt left knee visibly swollen. Pt states he has no current weakness. Pt alert andf (sic) oriented ..." Review of the triage vital signs at 1158 revealed T 100.5 rectal, P 140, RR 20, BP 114/61 and O2 94% on room air. Review revealed Patient #3 was triaged as a level 2 and had a pain level of 10/10 no documented location. Review of the provider notes documented at 1146 by MD #2 revealed " ...79-year-old male with past medical history of hypertension, hyperlipidemia, Afib/DVT currently on Eliquis presents with concern for leg pain. The patient states that he was recently admitted (admission was prior to ED visit #1 on 10/20/2019) where he had infection, EMS states that he had sepsis and he was recently discharged from the hospital. The patient is a poor historian and he describes that he has recently fallen approximately 3 days ago where he was sitting on the side of the bed after going to the toilet when he sat his bottom down but he missed the bed and he landed on the ground. States that his legs twisted underneath him and that is what causes his pain and he is not having any pain in his spine or in his lower bottom but is having complaints of pain over his left knee primarily over the posterior aspect. He denies any fevers that he is aware of. He otherwise denies any other complaints. He denies hitting his head or losing consciousness, no complaints of neck pain. He denies any complaints of chest pain shortness of breath abdominal pain. No dysuria. He denies any redness. Otherwise his history is limited and his wife is not here. Reportedly his lives home with his wife ...Findings ...Musculoskeletal: head/face atraumatic - No basilar skull signs, no palpable skull fractures., Other - Patient has a quarter-size chronic wound over his right lateral hip which appears to be chronic, has wound packing and does not appear acutely infected. He has no midline vertebral step-offs or deformities. He has no pelvic pain and no pain with range of motion on his bilateral hips. He has no pain in his right lower extremity from his hip down. He does have complaints of left knee pain and left distal femur pain. He does have small swelling here. He has no erythema. This appears to be warm however this is only over the area where his right knee will lay on his left leg as he turns to the left. He otherwise has no diffuse warmth. He does allow range of motion to 90 (degree sign) however this is painful over the posterior aspect of his knee. He has no significant distal tib-fib pain. No ankle pain. No asymmetric swelling or edema of his calf., no cervical spine tenderness, no thoracic spine tenderness, no lumbar spine tenderness ...Diagnostic Results: Knee X-ray 10/22/2019 1153 IMPRESSION: Distal left tibial metadiaphyseal fracture with displacement medially. Osteopenia noted. Joint effusion and degenerative joint changes in the left knee. Pelvis X-Ray 10/22/19 1153 IMPRESSION: No fracture. Sclerotic change over SI joints. No dislocation. Femur X-ray 10/22/19 12:00 IMPRESSION: Oblique fracture left femur distal metadiaphyseal with displacement of distal fragment medially. Joint effusion. Osteopenia diffusely. Chest X-Ray 10/22/19 1247 IMPRESSION: Left basilar airspace disease and small effusion, question changes of pneumonia. Mild interstitial prominence. Medical Decision Making: History examination as above. Patient presents after he has been complaining of a left knee pain since and was sent to the ER for evaluation of this and generalized weakness. On examination initially he is tachycardia in the 130s, feels warm but has no objective oral fever. Will obtain a rectal temp. He has a benign examination with no signs of head trauma, no complaints of headache, no complaints of neck pain. He is on Eliquis-will talk with his wife when she arrived to discuss exactly what happened. He denies hitting his head and at this time will hold on CT head imaging. He does have previous stroke and potentially memory problems which appears to be his baseline. The patient is not very clear about where he is hurting. He does have some warmth over his left knee but no erythema, full range of motion of his left knee but he does have pain the posterior aspect. Differential includes that he has a traumatic injury, obtain x-ray of his bilateral hips, left femur and his left knee. Does have a history of previous DVT in the past however he is on Eliquis. Obtain infectious workup as above given his tachycardia. He has a history of AFib, on diltiazem, unknown if he took his medications this morning. Will gently hydrate and also consider rate controlling agents. Monitor re-evaluate. Time 12:06p.m. The patient does have a rectal temperature of 100.5 (degree sign) F concerning for sepsis given his tachycardia. Will obtain lactic acid, blood cultures urine cultures. Will obtain a chest x-ray, urinalysis straight cath and will continue his workup. He currently does not show signs that would suggest meningitis or encephalitis. -will continue monitoring pending his family arrival ...Time 2:04pm.. Chest x-ray shows concern for likely left lower lobe pneumonia with small effusion. He is not requiring oxygen at this time. Lactic acid is elevated to 5. Status post 500 cc (cubic centimeter) of IV (intravenous) fluids, will continue 2500 cc for 30 cc/kilos fluid bolus. Will hydrate him gently at 120 cc/hour. He is still on a Cardizem drip as well as for his AFib with RVR (Rapid Ventricular Response). Status post vancomycin Zosyn as above, will add on azithromycin for atypical coverage. -x-ray shows that he has an obliquely oriented distal femur fracture on the left side with some medial angulation and an effusion associated with this. Feel that underlying fat embolus is less likely. Do not suspect underlying DVT (deep vein thrombosis) with PE (pulmonary embolism) given these anticoagulated. Time 2:26pm.. I spoke with Orthopedic surgery (MD Name) - at this time will place the patient in a knee immobilizer and he recommends traction that can be accomplished after the patient is admitted. -the patient did developed hypotension with attempts at rate control given his AFib with a RVR. He has received total 500 cc of LR (Lactated Ringers), he has been on LR drip and now his systolic is dropped to 79. Will pause diltiazem in the setting of sepsis with his hypotension, bolus IV fluids and started on amiodarone. -Will consult hospitalist for admission. Time 2:56pm.. I spoke with the hospitalist (MD Name), she agrees and accepts for admission to the ICU ...Spoke about Orthopedics recommendations as well ..." Review of the hematology results timed at 1215 revealed all normal results except for " ...WBC 13.8 H RBC 3.36 L Hgb 8.6 L Hct 27.2 L ...MCH 25.7 L ...Neutrophils # 10.7 H ...Chloride 109 H ...BUN 27 H Creatinine 1.4 H ....Glucose 181 H ...AST 11 L ...Albumin 2.7 L Globulin 4.6H Albumin/Globulin Ration 0.6 L ...Lactic Acid 5.0 H ...B-Natriuretic Peptide 541.6 H ..." Review of the "History and Physical" dated 10/22/2019 at 1508 revealed Patient #3 normally ambulated with a walker at home and was admitted to the ICU for " ...Suspected pneumonia Sepsis AFib with RVR Femur fracture Anemia Diabetes Mellitus AKI Elevated BNP." Review revealed Patient #3 had left hip ORIF (open reduction internal fixation) surgery on 10/25/2019 and was discharged to a skilled nursing facility on 11/04/2019.

Interview on 12/04/2019 at 1100 with MD #4 revealed he was the radiologist that read Patient #3's tibia/fibula x-ray from 10/20/2019. Interview revealed there were no fractures of the tibia or fibula on 10/20/2019. Interview revealed you would not be able to see a femur fracture on a tibia/fibula x-ray.

Interview on 12/04/2019 at 0930 with RN (Registered Nurse) #2 revealed she was the primary nurse for Patient #3 on the 10/20/2019 visit. Interview revealed she did not recall Patient #3. When asked about the pain assessment of left knee pain for Patient #3, RN #2 stated the patient would tell her the location of their pain and she would document that location in the medical record. Interview revealed she did not know if Patient #3 ambulated prior to discharge and normally RN #2 would put a nursing note about ambulation if the patient was ambulated.

Interview on 12/04/2019 at 1015 with MD #3 revealed he was the ED MD for Patient #3's 10/20/2019 visit. Interview revealed he vaguely recalled Patient #3. Interview revealed MD #3 "took care" during his assessment to ensure Patient #3 did not have a hip or knee fracture because he was elderly. Interview revealed MD #3 did range of motion and palpation and Patient #3 did not report any pain at that time. Interview revealed Patient #3 had left lower extremity pain and MD #3 focused on the left lower leg. Interview revealed MD #3 was not sure of Patient #3's mobility status and he stated, "I did not document well enough to recall his functional status." Interview revealed MD #3 did not know if Patient #3 was ambulatory prior to arrival and revealed he did not document that Patient #3 ambulated prior to discharge. Interview revealed MD #3 was told by MD #2 that Patient #3 had returned on 10/22/2019 and had a left femur fracture. Interview revealed MD #3 did not look at Patient #3's second visit but had "heightened awareness" on patients who had fallen to ensure all potential places of injury were reviewed. Interview revealed MD #3 felt Patient #3 had a thorough MSE and was stable for discharge, but he did "recognize an opportunity for improvement."

Interview on 12/03/2019 at 1645 with MD #2 revealed he was the ED MD for Patient #3's 10/22/2019 visit and recalled Patient #3. Interview revealed Patient #3 had come in with leg pain and had multiple other issues as well. Interview revealed the x-rays showed Patient #3 had a femur fracture. Interview revealed Patient #3 was a poor historian and was unable to directly point to where his pain was located. Interview revealed that is why MD #3 x-rayed Patient #3's left femur, pelvis, and left knee. Interview revealed MD #3 performed range of motion on Patient #3's knee and he tolerated it without pain. Interview revealed MD #3 recognized that Patient #3 had returned to the ED within 24 hours and looked at Patient #3's 10/20/2019 record to ensure a femur fracture was not missed but Patient #3 only had a tibia/fibula x-ray done.

Interview on 12/04/2019 at 2025 with MD #6 revealed he read Patient #3's 10/22/2019 x-rays. Interview revealed on Patient #3's left knee x-ray under impression it should say distal left femur metadiaphyseal fracture with displacement medially. Interview revealed MD #6 would not be able to see a distal tibia fracture on a knee x-ray and that was a documentation error. Interview revealed MD #3 wrote an addendum to the report during the interview.

The medical screening examination provided to Patient #3 during visit one (1) was not appropriate. The hospital staff did not ambulate the patient prior to discharge to determine if he was able to walk. During Patient #3's second visit to the DED, two days later, it was determined the patient had a fracture.

Based on policy and procedure review, medical record review, and staff and physician interviews, the hospital failed to ensure stabilization of a patient with an emergency medical condition for 1 of 5 patients with a chief complaint of fall (Patient #3).

The findings included:

Review on 12/04/2019 of a policy titled "Emergency Medical Screening" last reviewed 10/05/2016 revealed, " ...The following policy is designed to ensure that (Hospital A Named) provides emergency medical screening examinations to any individual for whom an exam or treatment is requested in compliance with the Emergency Medical Treatment and Active Labor Act ... This federal law requires that any such individuals presenting to any (Hospital A Named) location receive a medical screening examination by personnel who are qualified to provide such screenings by virtue of their education, training, credentials, and experience ... All emergency medical screenings must be conducted in a manner that is reasonably calculated to exclude the presence of an emergency medical condition. This may include the utilization of necessary test, ancillary services, and/or on-call specialists ..."

Review of the closed Dedicated Emergency Department (DED) medical record for Patient #3 (Visit #1) revealed a 79 -year-old male that presented to the DED via EMS on 10/20/2019 at 0328 with a chief complaint of fall and left lower leg pain. Review of the triage nursing notes documented at 0328 revealed "Pt c/o (complaint of) left lower leg pain after a fall tonight." Review of the triage vital signs at 0328 revealed T (temperature) 98.8, P (pulse) 106, RR (respiratory rate) 16, BP (blood pressure) 117/69, O2 (oxygen) 96% on room air. Review revealed a pain assessment of 10 out of 10 (pain scale where 0 is no pain and 10 is the worst pain) with no documented location and he was triaged as a level 4. Review of a nursing pain assessment at 0334 revealed Patient #3 had 6/10 pain in the left knee. Review of the provider notes at 0338 by Medical Doctor (MD) #3 revealed " ...Seventy-nine year male presents complaint of left lower leg pain. Context is patient sustained a fall just prior to arrival. His wife called EMS they initially refused transport but he patient was concerned and wanted to know if he had a fracture or not. He states the pain is located only to left lower leg does not hurt to left hip or left knee or left foot. Pain is of mild intensity, worse with palpation or movement ...Review of Systems ...Musculoskeletal: extremity pain, no extremity swelling ...Findings ...Musculoskeletal: head/face atraumatic, tenderness-Left lower leg ...Test Results: Results: reviewed & interpreted by me to support final diagnosis Diagnostic Results: Tibia/Fibula X-ray 10/20/19 0348 IMPRESSION: No acute ossesous abnormality ...Medical Decision Making ...79-year-old male presents with complaint of left lower leg pain. X-ray shows no fracture. Patient has no pain to the hip. No bleeding. No other injuries on exam. He is at his baseline with functional status. Will discharge home with instructions ..." Review revealed Patient #3 received 1,000 mg of Tylenol PO (by mouth) at 0445 and had a pain score of 8/10 documented as " ...Pain location: rle (right lower extremity) ..." Review revealed Patient #3 had a tibia and fibula x-ray signed at 0421 by MD #4 which stated " ...FINDINGS: There is not evidence of fracture or dislocation. Bones appear osteopenic ..." Review revealed Patient #3 was not ambulated prior to discharge. Review revealed Patient #3 was discharged home via wheelchair with his family at 0505.

Review of the closed DED medical record on 12/03/2019 for Patient #3 (Visit #2) revealed Patient #3 returned to the DED on 10/22/2019 at 1136 via EMS with a chief complaint of leg pain. Review of the triage nursing notes documented at 1158 revealed " ...pt complaining of bilateral leg pain from a fall that took place on Saturday. Pt left knee visibly swollen. Pt states he has no current weakness. Pt alert andf (sic) oriented ..." Review of the triage vital signs at 1158 revealed T 100.5 rectal, P 140, RR 20, BP 114/61 and O2 94% on room air. Review revealed Patient #3 was triaged as a level 2 and had a pain level of 10/10 no documented location. Review of the provider notes documented at 1146 by MD #2 revealed " ...79-year-old male with past medical history of hypertension, hyperlipidemia, Afib/DVT currently on Eliquis presents with concern for leg pain. The patient states that he was recently admitted (admission was prior to ED visit #1 on 10/20/2019) where he had infection, EMS states that he had sepsis and he was recently discharged from the hospital. The patient is a poor historian and he describes that he has recently fallen approximately 3 days ago where he was sitting on the side of the bed after going to the toilet when he sat his bottom down but he missed the bed and he landed on the ground. States that his legs twisted underneath him and that is what causes his pain and he is not having any pain in his spine or in his lower bottom but is having complaints of pain over his left knee primarily over the posterior aspect. He denies any fevers that he is aware of. He otherwise denies any other complaints. He denies hitting his head or losing consciousness, no complaints of neck pain. He denies any complaints of chest pain shortness of breath abdominal pain. No dysuria. He denies any redness. Otherwise his history is limited and his wife is not here. Reportedly his lives home with his wife ...Findings ...Musculoskeletal: head/face atraumatic - No basilar skull signs, no palpable skull fractures., Other - Patient has a quarter-size chronic wound over his right lateral hip which appears to be chronic, has wound packing and does not appear acutely infected. He has no midline vertebral step-offs or deformities. He has no pelvic pain and no pain with range of motion on his bilateral hips. He has no pain in his right lower extremity from his hip down. He does have complaints of left knee pain and left distal femur pain. He does have small swelling here. He has no erythema. This appears to be warm however this is only over the area where his right knee will lay on his left leg as he turns to the left. He otherwise has no diffuse warmth. He does allow range of motion to 90 (degree sign) however this is painful over the posterior aspect of his knee. He has no significant distal tib-fib pain. No ankle pain. No asymmetric swelling or edema of his calf., no cervical spine tenderness, no thoracic spine tenderness, no lumbar spine tenderness ...Diagnostic Results: Knee X-ray 10/22/2019 1153 IMPRESSION: Distal left tibial metadiaphyseal fracture with displacement medially. Osteopenia noted. Joint effusion and degenerative joint changes in the left knee. Pelvis X-Ray 10/22/19 1153 IMPRESSION: No fracture. Sclerotic change over SI joints. No dislocation. Femur X-ray 10/22/19 12:00 IMPRESSION: Oblique fracture left femur distal metadiaphyseal with displacement of distal fragment medially. Joint effusion. Osteopenia diffusely. Chest X-Ray 10/22/19 1247 IMPRESSION: Left basilar airspace disease and small effusion, question changes of pneumonia. Mild interstitial prominence. Medical Decision Making: History examination as above. Patient presents after he has been complaining of a left knee pain since and was sent to the ER for evaluation of this and generalized weakness. On examination initially he is tachycardia in the 130s, feels warm but has no objective oral fever. Will obtain a rectal temp. He has a benign examination with no signs of head trauma, no complaints of headache, no complaints of neck pain. He is on Eliquis-will talk with his wife when she arrived to discuss exactly what happened. He denies hitting his head and at this time will hold on CT head imaging. He does have previous stroke and potentially memory problems which appears to be his baseline. The patient is not very clear about where he is hurting. He does have some warmth over his left knee but no erythema, full range of motion of his left knee but he does have pain the posterior aspect. Differential includes that he has a traumatic injury, obtain x-ray of his bilateral hips, left femur and his left knee. Does have a history of previous DVT in the past however he is on Eliquis. Obtain infectious workup as above given his tachycardia. He has a history of AFib, on diltiazem, unknown if he took his medications this morning. Will gently hydrate and also consider rate controlling agents. Monitor re-evaluate. Time 12:06p.m. The patient does have a rectal temperature of 100.5 (degree sign) F concerning for sepsis given his tachycardia. Will obtain lactic acid, blood cultures urine cultures. Will obtain a chest x-ray, urinalysis straight cath and will continue his workup. He currently does not show signs that would suggest meningitis or encephalitis. -will continue monitoring pending his family arrival ...Time 2:04pm.. Chest x-ray shows concern for likely left lower lobe pneumonia with small effusion. He is not requiring oxygen at this time. Lactic acid is elevated to 5. Status post 500 cc (cubic centimeter) of IV (intravenous) fluids, will continue 2500 cc for 30 cc/kilos fluid bolus. Will hydrate him gently at 120 cc/hour. He is still on a Cardizem drip as well as for his AFib with RVR (Rapid Ventricular Response). Status post vancomycin Zosyn as above, will add on azithromycin for atypical coverage. -x-ray shows that he has an obliquely oriented distal femur fracture on the left side with some medial angulation and an effusion associated with this. Feel that underlying fat embolus is less likely. Do not suspect underlying DVT (deep vein thrombosis) with PE (pulmonary embolism) given these anticoagulated. Time 2:26pm.. I spoke with Orthopedic surgery (MD Name) - at this time will place the patient in a knee immobilizer and he recommends traction that can be accomplished after the patient is admitted. -the patient did developed hypotension with attempts at rate control given his AFib with a RVR. He has received total 500 cc of LR (Lactated Ringers), he has been on LR drip and now his systolic is dropped to 79. Will pause diltiazem in the setting of sepsis with his hypotension, bolus IV fluids and started on amiodarone. -Will consult hospitalist for admission. Time 2:56pm.. I spoke with the hospitalist (MD Name), she agrees and accepts for admission to the ICU ...Spoke about Orthopedics recommendations as well ..." Review of the hematology results timed at 1215 revealed all normal results except for " ...WBC 13.8 H RBC 3.36 L Hgb 8.6 L Hct 27.2 L ...MCH 25.7 L ...Neutrophils # 10.7 H ...Chloride 109 H ...BUN 27 H Creatinine 1.4 H ....Glucose 181 H ...AST 11 L ...Albumin 2.7 L Globulin 4.6H Albumin/Globulin Ration 0.6 L ...Lactic Acid 5.0 H ...B-Natriuretic Peptide 541.6 H ..." Review of the "History and Physical" dated 10/22/2019 at 1508 revealed Patient #3 normally ambulated with a walker at home and was admitted to the ICU for " ...Suspected pneumonia Sepsis AFib with RVR Femur fracture Anemia Diabetes Mellitus AKI Elevated BNP." Review revealed Patient #3 had left hip ORIF (open reduction internal fixation) surgery on 10/25/2019 and was discharged to a skilled nursing facility on 11/04/2019.

Interview on 12/04/2019 at 1100 with MD #4 revealed he was the radiologist that read Patient #3's tibia/fibula x-ray from 10/20/2019. Interview revealed there were no fractures of the tibia or fibula on 10/20/2019. Interview revealed you would not be able to see a femur fracture on a tibia/fibula x-ray.

Interview on 12/04/2019 at 0930 with RN (Registered Nurse) #2 revealed she was the primary nurse for Patient #3 on the 10/20/2019 visit. Interview revealed she did not recall Patient #3. When asked about the pain assessment of left knee pain for Patient #3, RN #2 stated the patient would tell her the location of their pain and she would document that location in the medical record. Interview revealed she did not know if Patient #3 ambulated prior to discharge and normally RN #2 would put a nursing note about ambulation if the patient was ambulated.

Interview on 12/04/2019 at 1015 with MD #3 revealed he was the ED MD for Patient #3's 10/20/2019 visit. Interview revealed he vaguely recalled Patient #3. Interview revealed MD #3 "took care" during his assessment to ensure Patient #3 did not have a hip or knee fracture because he was elderly. Interview revealed MD #3 did range of motion and palpation and Patient #3 did not report any pain at that time. Interview revealed Patient #3 had left lower extremity pain and MD #3 focused on the left lower leg. Interview revealed MD #3 was not sure of Patient #3's mobility status and he stated, "I did not document well enough to recall his functional status." Interview revealed MD #3 did not know if Patient #3 was ambulatory prior to arrival and revealed he did not document that Patient #3 ambulated prior to discharge. Interview revealed MD #3 was told by MD #2 that Patient #3 had returned on 10/22/2019 and had a left femur fracture. Interview revealed MD #3 did not look at Patient #3's second visit but had "heightened awareness" on patients who had fallen to ensure all potential places of injury were reviewed. Interview revealed MD #3 felt Patient #3 had a thorough MSE (medical screening exam) and was stable for discharge, but he did "recognize an opportunity for improvement."

Interview on 12/03/2019 at 1645 with MD #2 revealed he was the ED MD for Patient #3's 10/22/2019 visit and recalled Patient #3. Interview revealed Patient #3 had come in with leg pain and had multiple other issues as well. Interview revealed the x-rays showed Patient #3 had a femur fracture. Interview revealed Patient #3 was a poor historian and was unable to directly point to where his pain was located. Interview revealed that is why MD #3 x-rayed Patient #3's left femur, pelvis, and left knee. Interview revealed MD #3 performed range of motion on Patient #3's knee and he tolerated it without pain. Interview revealed MD #3 recognized that Patient #3 had returned to the ED within 24 hours and looked at Patient #3's 10/20/2019 record to ensure a femur fracture was not missed but Patient #3 only had a tibia/fibula x-ray done.

Interview on 12/04/2019 at 2025 with MD #6 revealed he read Patient #3's 10/22/2019 x-rays. Interview revealed on Patient #3's left knee x-ray under impression it should say distal left femur metadiaphyseal fracture with displacement medially. Interview revealed MD #6 would not be able to see a distal tibia fracture on a knee x-ray and that was a documentation error. Interview revealed MD #3 wrote an addendum to the report during the interview.

The hospital failed to provide stabilization for Patient #3's fractured leg during the first DED visit. Patient #3 was discharged without staff ambulating him, delaying stabilization.