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Based on interview, medical record and document review the Hospital failed to treat within their capabilities, a patient in the Emergency Department (ED) with an emergency medical condition. The deficient practice affected one of twenty patient records sampled from the ED log through May to November 2010.

Findings include:

The Hospital's Policy regarding "EMTALA Transfer of Patients" revised 9/08 reviewed on 11/8/10 states, "Prior to transfer, the patient should be stabilized to the extent possible so that the patient's condition will not significantly deteriorate during the transfer." The hospital failed to follow this policy and discharged Patient # 18 from the ED on 10/27/10 prior to providing further examination and stabilizing treatment. During the investigation, review of hospital documents revealed the capability to perform a lab test known as a D-dimer (lab test to help diagnose the condition of thrombosis, the formation of a blood clot inside a vessel) and initiate anticoagulation treatment along with coagulation studies; or transfer to another hospital with the capability to perform an immediate Doppler exam; or inpatient admission.

Patient #18's medical record reviewed on 11/8/10 revealed they presented to the ED on 10/20/10 at 1:03 pm complaining of right knee pain and swelling. Staff A, MD (medical doctor), performed a Medical Screening Examination (MSE) and documented the patient had a right knee abscess with onset five days ago; that patient # 18 ' s symptoms included pain, fever and cellulitis (skin infection) which had worsened over the last day; and that patient #18 complained of pain with passive flexion of the right knee joint and weight bearing. At 1:41 pm, the ED physician administered a local anesthesia and performed an arthrocentesis (removal of fluid) of the right knee, applied a dressing, and administered pain medications and antibiotics. At 4:25 pm the ED discharged patient #18 with instructions to follow up with a family physician or return to the ED for a recheck in two - three days.

Patient #18's medical record reviewed on 11/9/10 revealed they presented a second time to the ED on 10/23/10 at 1:54 pm complaining of a worsening right knee infection. Staff B, MD, assessed patient #18 in the ED and documented that patient # 18 had been seen in the ED 3 days ago for a "developing infection" and that the symptoms had "worsened while on doxy (name of antibiotic)" and; "Right knee area shows 3 cm pus-filled bulla, slight erythema (redness) and tenderness." Staff B anesthetized patient # 18 ' s right knee, incised it with a scalpel to drain pus and then packed the wound. The ED applied a dressing and a coban knee immobilizer. At 2:58 pm the ED discharged patient #18 with instructions to continue with the antibiotic, apply heat and follow up if not better next week.

Patient #18's medical record reviewed on 11/9/10 revealed they presented a third time to the ED on 10/27/10 at 6:43 pm with right calf pain and swelling. The ED nurse documented that patient # 18 rated his right lower leg pain 8 on a scale of 1 -10 (10 is the worst pain). At 7:47 pm, Staff B, assessed patient #18 in the ED and documented, "patient complained of increasing pain in the right calf", that patient #18 had been less active due to care of the abscess, and that the right calf measured 2.5 cm larger than the left calf (immobility is known possible risk factor for developing a lower limb blood clot, also known as a deep vein thrombosis or DVT). The ED physician documented he arranged for a venous Doppler study to be performed at the hospital's outpatient department the next day (10/28/10) to rule out a DVT (a DVT and its sequela, a pulmonary embolism (blood clot in the lung) can cause serious, potentially life threatening complications if not treated) and at 8:00 pm discharged patient #18 home.

Patient #18 presented to the Emergency Department at a second hospital (Hospital B) on 10/28/10 at 6:28 pm complaining of lower right extremity pain and shortness of breath. Patient #18 received further examination and was admitted for treatment of an emergency medical condition, a blood clot in the right lung.

Staff B, MD, during the interview on 11/10/10 at 7:20 am submitted the following documentation: "They saw the patient on 10/27/10. Patient #18 had been treated for an abscess on the right leg, just below the knee. This required antibiotics and I&D (incision and drainage). On the day of this visit, patient #18 had added complaints of swelling in right calf and slight pain in right calf. Examination showed healing infection on anterior of leg. Calf was very slightly tender to examination and was measured as one inch larger that the left calf. No other findings noted. Patient #18 did not have any findings above knee, nor did he have any pulmonary complaints. Felt that DVT was possible, but given his other problems, not the only explanation for his symptoms. Felt that if the patient had DVT, that it was confined to calf, making low probability for PE (pulmonary embolism). Therefore ordered outpatient Doppler exam the next day."

The statutorily mandated medical peer review obtained on 12/13/10 reported the MSE completed on 10/27/10 at Miami County Medical Center determined the presence of an emergency medical condition. Patient #18 complained of pain and swelling in the right calf consistent with the possibility of an acute DVT, which is an emergency medical condition. Patient #18 was discharged without receiving treatment for an emergency medical condition.

Based on interview, medical record and document review the Hospital failed to treat within their capabilities, a patient in the Emergency Department (ED) with an emergency medical condition. The deficient practice affected one of twenty patient records sampled from the ED log through May to November 2010.

Findings include:

The Hospital's Policy regarding "EMTALA Transfer of Patients" revised 9/08 reviewed on 11/8/10 states, "Prior to transfer, the patient should be stabilized to the extent possible so that the patient's condition will not significantly deteriorate during the transfer." The hospital failed to follow this policy and discharged Patient # 18 from the ED on 10/27/10 prior to providing further examination and stabilizing treatment. During the investigation, review of hospital documents revealed the capability to perform a lab test known as a D-dimer (lab test to help diagnose the condition of thrombosis, the formation of a blood clot inside a vessel) and initiate anticoagulation treatment along with coagulation studies; or transfer to another hospital with the capability to perform an immediate Doppler exam; or inpatient admission.

Patient #18's medical record reviewed on 11/8/10 revealed they presented to the ED on 10/20/10 at 1:03 pm complaining of right knee pain and swelling. Staff A, MD (medical doctor), performed a Medical Screening Examination (MSE) and documented the patient had a right knee abscess with onset five days ago; that patient # 18 ' s symptoms included pain, fever and cellulitis (skin infection) which had worsened over the last day; and that patient #18 complained of pain with passive flexion of the right knee joint and weight bearing. At 1:41 pm, the ED physician administered a local anesthesia and performed an arthrocentesis (removal of fluid) of the right knee, applied a dressing, and administered pain medications and antibiotics. At 4:25 pm the ED discharged patient #18 with instructions to follow up with a family physician or return to the ED for a recheck in two - three days.


Patient #18's medical record reviewed on 11/9/10 revealed they presented a second time to the ED on 10/23/10 at 1:54 pm complaining of a worsening right knee infection. Staff B, MD, assessed patient #18 in the ED and documented that patient # 18 had been seen in the ED 3 days ago for a "developing infection" and that the symptoms had "worsened while on doxy (name of antibiotic)" and; "Right knee area shows 3 cm pus-filled bulla, slight erythema (redness) and tenderness." Staff B anesthetized patient # 18 ' s right knee, incised it with a scalpel to drain pus and then packed the wound. The ED applied a dressing and a coban knee immobilizer. At 2:58 pm the ED discharged patient #18 with instructions to continue with the antibiotic, apply heat and follow up if not better next week.

Patient #18's medical record reviewed on 11/9/10 revealed they presented a third time to the ED on 10/27/10 at 6:43 pm with right calf pain and swelling. The ED nurse documented that patient # 18 rated his right lower leg pain 8 on a scale of 1 -10 (10 is the worst pain). At 7:47 pm, Staff B, assessed patient #18 in the ED and documented, "patient complained of increasing pain in the right calf", that patient #18 had been less active due to care of the abscess, and that the right calf measured 2.5 cm larger than the left calf (immobility is known possible risk factor for developing a lower limb blood clot, also known as a deep vein thrombosis or DVT). The ED physician documented he arranged for a venous Doppler study to be performed at the hospital's outpatient department the next day (10/28/10) to rule out a DVT (a DVT and its sequela, a pulmonary embolism (blood clot in the lung) can cause serious, potentially life threatening complications if not treated) and at 8:00 pm discharged patient #18 home.

Patient # 18's medical records do not contain a description of his level of activity (or extent of inactivity) after performing the arthrocentesis on 10/20/10 or developing the right knee abscess approximately five days prior; and/or applying the coban knee immobilizer after the incision and drainage on 10/23/10, and/or an assessment of whether patient # 18's symptoms (right lower calf swelling and pain) on 10/28/10 were continuous or occasional, or what if anything seemed to improve or worsen his symptoms.

Patient #18 presented to the Emergency Department at a second hospital (Hospital B) on 10/28/10 at 6:28 pm complaining of lower right extremity pain and shortness of breath. Patient #18 received further examination and was admitted for treatment of an emergency medical condition, a blood clot in the right lung.

Staff B, MD, during the interview on 11/10/10 at 7:20 am submitted the following documentation: "They saw the patient on 10/27/10. Patient #18 had been treated for an abscess on the right leg, just below the knee. This required antibiotics and I&D (incision and drainage). On the day of this visit, patient #18 had added complaints of swelling in right calf and slight pain in right calf. Examination showed healing infection on anterior of leg. Calf was very slightly tender to examination and was measured as one inch larger that the left calf. No other findings noted. Patient #18 did not have any findings above knee, nor did he have any pulmonary complaints. Felt that DVT was possible, but given his other problems, not the only explanation for his symptoms. Felt that if the patient had DVT, that it was confined to calf, making low probability for PE (pulmonary embolism). Therefore ordered outpatient Doppler exam the next day."

The statutorily mandated medical peer review obtained on 12/13/10 reported the MSE completed on 10/27/10 at Miami County Medical Center determined the presence of an emergency medical condition. Patient #18 complained of pain and swelling in the right calf consistent with the possibility of an acute DVT, which is an emergency medical condition. Patient #18 was discharged without receiving treatment for an emergency medical condition.