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Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, and physician and staff interviews, the hospital failed to provide an appropriate medical screening examination and necessary stabilizing treatment, within the capability of the hospital's DED, including ancillary services routinely available to the DED, for 1 of 27 sampled patients (Patient #11) presenting to the hospital's DED.

The findings include:

1. Based on closed DED (Dedicated Emergency Department) medical record reviews, ambulance trip report, policies and procedures, physician and staff interviews, the hospital failed to provide for an appropriate medical screening examination, within the capability of the hospital's DED for an individual whose presenting signs and symptoms were complaint of right arm pain and right leg pain status post a fall for 1 (#11) of 27 sampled patients..

~cross refer to 489.24(a), Medical Screening Exam - Tag A2406.

2. The hospital failed to provide necessary stabilizing treatment for 1 of 27 sampled patients (Patient #11) presenting to the hospital's DED.

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

Based on closed DED (Dedicated Emergency Department) medical record reviews, ambulance trip report, policies and procedures, physician and staff interviews, the hospital failed to provide for an appropriate medical screening examination, within the capability of the hospital's DED for an individual whose presenting signs and symptoms were complaint of right arm pain and right leg pain status post a fall for 1 (Patient #11) of 27 sampled patients.

The findings include:

1. Hospital A (Wayne Memorial Hospital) closed medical record review for Patient #11 revealed a 77 year old Caucasian female presented by ambulance to Hospital A's DED on 08/22/2016 at 1748. Review of the ambulance run report, written by Paramedic #1 revealed,"...Upon arrival on scene patient found sitting on the floor in the lobby. People on scene stated that she tripped over the chair and then tripped over someone elses (sic) walker. The section of the ambulance report titled "Chief Complaint' was listed as "Extremity-Lower, Extremity-Upper." Patient is complaining of right arm pain and right leg pain behind her upper thigh. Patient placed on stretcher and taken out to unit... Arrived at WMH (Wayne Memorial Hospital ).Patient taken inside and placed in ER (Emergency Room) bed...Report and care handed over to receiving nurse at WMH." Hospital A's initial vital signs at 1749 were: Blood Pressure (BP) 145/75 mmHg; Pulse (P) 75; Respirations (R) 20; Temperature (T) 96.9 ° (degrees) F (Fahrenheit); and Pulse Oximetry (SpO2) 95 % Room Air (RA). Triage assessment documentation written on 08/22/2016 at 1749 by Registered Nurse (RN) #1, revealed, "Pnt (patient) on Plavix tripped and fell today at the nursing facility. C/o (complains of) right arm pain. Skin tear on right elbow. Denies LOC (loss of consciousness) or hitting her head... Triage Pain Assessment Pain intensity (0-10) 0 (no pain) Pain Scale Used Numerical ..." Review of provider documentation written by a scribe for Medical Doctor (MD) #1, who electronically signed on 08/22/2016 at 2022 revealed,"...History of Present Illness: 77-year-old female presents to the ED via EMS (Emergency Medical Services) for evaluation of fall. Patient complains of right hand pain and right knee pain onset after a fall at nursing facility when she was trying to get out of her chair. She reports right-sided numbness from an old CVA (Cerebral Vascular Accident -stroke). There are no aggravating or alleviating factors reported. Patient denies any loss of consciousness or head injury. She has a past medical history of cancer and stroke. The patient is not a good historian... Review of Systems Constitutional: No complaints Head: No complaints EENT: No complaints Cardiovascular: No complaints Respiratory: No complaints GI: No complaints Genitourinary: No complaints Musculoskeletal: Joint Pain (Right hand pain, right knee pain). The medical record lacked documentation that ROM (range of motion) of the patient's lower extremities were addressed, despite the EMT's hand off report to the ED nurse the patient was complaining of right leg pain. Neurological: No complaints Skin: No complaints Psychiatric: No complaints Hem/Lym/End: No complaints ROS Review: All other systems reviewed & negative except as above -Physical Examination Constitutional: Well Developed, Well Nourished HEENT: PERRL Neck: Non-tender, supple Cardiopulmonary: Normal, RRR, No: Murmur Lungs: CTA Chest: Normal Abdomen: Normal, Soft, Non-tender, No: Distended Back: Normal. Atraumatic Extremities: Other (Right posterior hand with swelling and bruising at the base of first finger) Neurological: Alert and Oriented x 3, CN II-XII Intact Skin: Normal No: Rash Psychiatric: Normal, Mood (Normal) Treatment: Patient is treated with hydrocodone 5/325 mg by mouth. Patient is encouraged to follow-up with orthopedic. Orders: ELBOW RIGHT... FOREARM RIGHT ...HAND RIGHT ...KNEE RIGHT (X-Rays) ...Elevate Extremity ... Ice Pack... Immobilize Affected Extremity... NPO... Neurovascular Checks... Notify Provider Immediately if compromised... Medical Decisions: Nurses Notes reviewed, discussed w/ (with) patient, discussed results (She is notified of first metacarpal fractures on the right hand distally), Discussed need for f/u (follow up), X-rays reviewed (Right hand X-ray - shows 1st metacarpal fracture per my read, elbow and knee x-ray - negative per my read) Plan: Discharge Condition: Improved, Stable Instruction: Hand Fracture, Splint Care Prescriptions: Hydrocodone Bit/Acetaminophen [Norco 5/325] 1 tab PO (by mouth) Q4-6 PRN (as needed) ... Additional Instructions: Call orthopedics to arrange follow-up Clinical Impression: Fall, Fracture of metacarpal base, first, right hand, closed." An ED Procedures note written by Physician's Assistant (PA) #1 on 08/22/2016 at 1951 revealed, "...I placed her in a volar splint with web roll and padding for hand fracture. She had good neuro status pre-and post-splinting was able to move her fingers. She had no complication with a (sic) splinting." Radiology Report dictated by Radiologist #1 on 08/22/2016 at 1957, revealed, " ...FINDINGS: RIGHT KNEE: AP, lateral, and oblique projections of the right knee demonstrate diffuse osteopenia (bones are weaker that normal) without acute fracture or dislocation. Alignment is anatomic and articular cartilage spaces are maintained on these nonweightbearing projections. There is a trace knee joint effusion. Scattered vascular calcifications. Mild anterior soft tissue swelling. RIGHT ELBOW: AP (Anterior/Posterior) , lateral, and oblique projections of the right elbow demonstrate no acute fracture or dislocation. There is diffuse osteopenia. No findings to suggest elbow joint effusion. No definite focal soft tissue swelling. RIGHT FOREARM: AP and lateral projections of the right forearm demonstrate no acute fracture or dislocation. Diffuse osteopenia. No focal soft tissue swelling identified. RIGHT HAND: PA, lateral, and oblique projections of the right hand demonstrate a mildly comminuted fracture of the head of the index finger metacarpal with some mild medial displacement. There is diffuse osteopenia. Soft tissue swelling adjacent to the second metacarpal. No additional fracture. STT and thumb CMC degenerative osteoarthritis. IMPRESSION: 1. Mildly displaced fracture of the head of the index finger metacarpal. 2. No acute osseous abnormality at the right knee, right elbow, or right forearm. 3. Diffuse osteopenia." An ED Disposition note written by RN #2 on 08/22/2016 at 2016 revealed, "...Pain Intensity (0-10) 4..." No location of the reported pain was documented. Review revealed Patient #11 was transported back to her assisted living facility by wheelchair van. Patient #11 was discharged at 2018. Review of the wheelchair van run report, written by EMT #1 revealed, "U/A (upon arrival) @ (at) (Hospital A) pt (patient) in bed alert. Pt transferred to w/c (wheelchair), secured, loaded into wc (wheelchair) van, secured & transported to residence (address). U/A pt transferred to chair & secured."

Telephone interview conducted with Paramedic #1 on 03/01/2017 at 1145 revealed Patient #11 complained of right arm pain and right leg pain behind her upper thigh. Paramedic #1 could not recall whether or not Patient #11 could bear weight. Interview reveled when arriving at Hospital A, the receiving nurse is given a verbal patient report, and the complete run report is generally completed upon return to their station. Interview revealed, "The hospital gets a 'Reader's Digest' version of the run report prior to our departure, and unless requested otherwise, that is all the hospital gets."

Interview conducted with RN #1 on 03/02/2017 at 0945 revealed she did not recall Patient #11. RN #1 reported that according to hospital documentation, it did not appear that EMS reported Patient #11 complaining of leg pain. Interview could not reveal any explanation of the complaint of right arm pain in the triage note, and a pain scale rating of 0 (zero) upon triage. Interview revealed, "I wouldn't have put 0 if the patient reported pain."

Physician interview was conducted with MD #1 on 03/01/2017 at 0900. Interview revealed Patient #11 seemed coherent, but "ill" upon assessment. Patient #11 was complaining of right forearm pain. MD #1 advised he did not recall Patient #11 complaining of any lower extremity pain. Interview revealed this was verified by nurse documentation. Interview revealed it was never reported to MD #1 that Patient #11 had complained of lower extremity pain to EMS, and EMS run reports are not generally available to Hospital A's ED physicians at the time of physician assessment. Interview revealed range of motion assessments were performed on Patient #11's upper extremities, and anterior pressure assessments were performed on her hips, shoulders, elbows, and wrists; to which she did not report pain. MD #1 advised this was his normal assessment for fall patients. Interview revealed nurses follow protocols prior to physician assessment, and if the patient had reported pain, she would have gotten X-rays wherever pain was reported. Interview revealed there was no attempt to ambulate Patient #11 prior to her discharge. The facility failed to ensure that an approrpiate medical examination was provided as evidenced by failing to address the patients presenting complaint of right leg pain behing her upper thigh for patient #11 on 8/22/2016.


Record review revealed Patient #11 returned to Hospital A's DED on 08/24/2016. Review of provider documentation written by MD #2 on 08/24/2016 at 1610 revealed, "...History of Present Illness: 77-year-old female presents to the emergency department via... EMS complaining of hip pain. Patient reports Monday (08/22/2016) she was trying to get out of her recliner when her shoe got caught on the chair causing her to fall and injure her right hip. She was seen in the emergency department following the incident, and had an x-ray of her right arm/hand, right knee, right femur, and right lower leg; fracture noted to the right first metacarpal. Patient states she has not been ambulatory at any point since the incident, and following discharge from the emergency department was placed in her recliner, but unable to walk or get out of the chair. She has no other complaints at this time..." A hip x-ray was performed, which identified a "right femoral neck fracture." While in Hospital A's DED a chest x-ray was also performed. A radiology report, dictated by Radiologist #1 on 08/24/2016 at 1104, revealed, "...IMPRESSION... 2. Age-indeterminate and possibly acute right proximal humerus fracture with possible intertrochanteric extension and varus angulation..." Review revealed Patient #11 was admitted to Hospital A, and received surgical repair of her hip fracture. A Provider Note written by Hospitalist #1 on 08/28/2016 at 1321 revealed, "...HISTORY OF PRESENT ILLNESS: Patient seen to follow-up right hip fracture, postop day #3... Later on as told by nursing that the daughter had noticed that the patient seemed to not use her shoulder very well since this recent fall. Patient had not mentioned any pain in this area. However elected to order an x-ray at the request of the daughter and the nurse. The x-ray did in fact later show a fracture. Discharge was cancelled. Patient was to be evaluated by orthopedics..." Orthopedic consult recommended non-operative management of the shoulder fracture, and Patient #11 was discharged from Hospital A on 08/29/2016.

Physician interview was conducted with MD #2 on 03/01/2017 at 1000. Interview revealed a chest x-ray was ordered for Patient #11 as a pre-operative measure, and not based upon clinical presentation. Interview revealed, "Not all radiology reports are called to me unless radiology thinks it's something acute. It's really radiologist discretion. I don't think it (the shoulder fracture) was called. If it was I would have mentioned it in my note. It's obviously there, but the missed hip was focused on at the time. The treatment (for the shoulder fracture) would have been a sling. This patient was not placed in a sling, according to the record."


The facility's policy and procedure titled "EMTALA: General Guidelines" PolicyStatID; 1627835, last last revised : 08/2016 was reviewed. The stated in part, "Purpose: To establish guidelines for compliance with the Emergency Medical Treatment and Labor ACT (EMTALA)...g. Medical Screening Examination-shall mean an examination conducted within the capability of the WMH (Wayne memorial Hospital ) Emergency Department , including the use of appropriate ancillary services that are routinely available to WMH, as will reasonably disclose the presence or absence of an Emergency medical Condition. A Medical Screening Examination is not an isolated event; rather an ongoing process; however, not all Medical Screening Exams must be equally extensive, rather the scope of the exam should be commensurate with the individuals's presenting medical condition to determine if an emergency medical exists, as deemed necessary by the examining qualified medical provider conducting the screening examination."

Based on hospital policy review, closed DED (Dedicated Emergency Department) medical record reviews, and physician and staff interviews, the hospital failed to provide necessary stabilizing treatment for 1 of 27 sampled patients (Patient #11) presenting to the hospital's DED.

The findings include:

1. Review of policy titled, "EMTALA:Medical Screening Exam, Stabilization, and Refusal of Treatment" last revised: 08/2016, revealed, "...PROCEDURE OUTLINING THE STABILIZATION PROCESS STEPS... 1. EMTALA applies until the Medical Screening Examination is done and it is determined that the patient does not have an Emergency Medical Condition, or the patient is -Stabilized for Discharge - Admitted - Appropriately Transferred 2. If an Emergency Medical Condition exists, medical treatment within the capabilities of the staff and facilities routinely available ("Capacity") will be provided to stabilize the individual prior to consideration of discharge... 4. Stabilized for discharge shall mean that it has been determined, within reasonable medical probability, that an individual has reached the point where his/her continued care, including diagnostic work-up and treatment, could be reasonably performed on an outpatient basis or later as an inpatient provided the patient is given a plan for appropriate follow-up care with the discharge instructions..."

Hospital A closed medical record review for Patient #11 revealed a 77 year old Caucasian female presented by ambulance to Hospital A's DED on 08/22/2016 at 1748. Review of the ambulance run report, written by Paramedic #1 revealed,"...Upon arrival on scene patient found sitting on the floor in the lobby. People on scene stated that she tripped over the chair and then tripped over someone elses (sic) walker. The section of the ambulance report titled "Chief Complaint' was listed as "Extremity-Lower, Extremity-Upper." Patient is complaining of right arm pain and right leg pain behind her upper thigh.." Hospital A's initial vital signs at 1749 were: Blood Pressure (BP) 145/75 mmHg; Pulse (P) 75; Respirations (R) 20; Temperature (T) 96.9 ° (degrees) F (Fahrenheit); and Pulse Oximetry (SpO2) 95 % Room Air (RA). Triage assessment documentation written on 08/22/2016 at 1749 by Registered Nurse (RN) #1, revealed, "Pnt (patient) on Plavix tripped and fell today at the nursing facility. C/o (complains of) right arm pain. Skin tear on right elbow. Denies LOC (loss of consciousness) or hitting her head... Triage Pain Assessment Pain intensity (0-10) 0 (no pain) Pain Scale Used Numerical ..." Review of provider documentation written by a scribe for Medical Doctor (MD) #1, who electronically signed on 08/22/2016 at 2022 revealed,"...History of Present Illness: 77-year-old female presents to the ED via EMS (Emergency Medical Services) for evaluation of fall. Patient complains of right hand pain and right knee pain onset after a fall at nursing facility when she was trying to get out of her chair. She reports right-sided numbness from an old CVA. There are no aggravating or alleviating factors reported. Patient denies any loss of consciousness or head injury. She has a past medical history of cancer and stroke. The patient is not a good historian... Review of Systems Constitutional: No complaints Head: No complaints EENT: No complaints Cardiovascular: No complaints Respiratory: No complaints GI: No complaints Genitourinary: No complaints Musculoskeletal: Joint Pain (Right hand pain, right knee pain) There was no documentation that the ROM (range of motion) of the patient's lower extremities were addressed, despite the EMT's hand off report to the ED nurse the patient was complaining of right leg pain. Neurological: No complaints Skin: No complaints Psychiatric: No complaints Hem/Lym/End: No complaints ROS Review: All other systems reviewed & negative except as above -Physical Examination Constitutional: Well Developed, Well Nourished HEENT: PERRL Neck: Non-tender, supple Cardiopulmonary: Normal, RRR, No: Murmur Lungs: CTA Chest: Normal Abdomen: Normal, Soft, Non-tender, No: Distended Back: Normal. Atraumatic Extremities: Other (Right posterior hand with swelling and bruising at the base of first finger) Neurological: Alert and Oriented x 3, CN II-XII Intact Skin: Normal No: Rash Psychiatric: Normal, Mood (Normal) Treatment: Patient is treated with hydrocodone 5/325 mg by mouth. Patient is encouraged to follow-up with orthopedic. Orders: ELBOW RIGHT... FOREARM RIGHT ...HAND RIGHT ...KNEE RIGHT (X-Rays) ...Elevate Extremity ... Ice Pack... Immobilize Affected Extremity... NPO... Neurovascular Checks... Notify Provider Immediately if compromised... Medical Decisions: Nurses Notes reviewed, discussed w/ (with) patient, discussed results (She is notified of first metacarpal fractures on the right hand distally), Discussed need for f/u (follow up), X-rays reviewed (Right hand X-ray - shows 1st metacarpal fracture per my read, elbow and knee x-ray - negative per my read) Plan: Discharge Condition: Improved, Stable Instruction: Hand Fracture, Splint Care Prescriptions: Hydrocodone Bit/Acetaminophen [Norco 5/325] 1 tab PO Q4-6 PRN ... Additional Instructions: Call orthopedics to arrange follow-up Clinical Impression: Fall, Fracture of metacarpal base, first, right hand, closed." An ED Procedures note written by Physician's Assistant (PA) #1 on 08/22/2017 at 1951 revealed, "...I placed her in a volar splint with web roll and padding for hand fracture. She had good neuro status pre-and post-splinting was able to move her fingers. She had no complication with a (sic) splinting." Radiology Report dictated by Radiologist #1 on 08/22/2016 at 1957, revealed, " ...FINDINGS: RIGHT KNEE: AP, lateral, and oblique projections of the right knee demonstrate diffuse osteopenia without acute fracture or dislocation. Alignment is anatomic and articular cartilage spaces are maintained on these nonweightbearing projections. There is a trace knee joint effusion. Scattered vascular calcifications. Mild anterior soft tissue swelling. RIGHT ELBOW: AP, lateral, and oblique projections of the right elbow demonstrate no acute fracture or dislocation. There is diffuse osteopenia. No findings to suggest elbow joint effusion. No definite focal soft tissue swelling. RIGHT FOREARM: AP and lateral projections of the right forearm demonstrate no acute fracture or dislocation. Diffuse osteopenia. No focal soft tissue swelling identified. RIGHT HAND: PA, lateral, and oblique projections of the right hand demonstrate a mildly comminuted fracture of the head of the index finger metacarpal with some mild medial displacement. There is diffuse osteopenia. Soft tissue swelling adjacent to the second metacarpal. No additional fracture. STT and thumb CMC degenerative osteoarthritis. IMPRESSION: 1. Mildly displaced fracture of the head of the index finger metacarpal. 2. No acute osseous abnormality at the right knee, right elbow, or right forearm. 3. Diffuse osteopenia." An ED Disposition note written by RN #2 on 08/22/2016 at 2016 revealed, "...Pain Intensity (0-10) 4..." No location of the reported pain was documented. Review revealed Patient #11 was transported back to her assisted living facility by wheelchair van. Patient #11 was discharged at 2018. Review of the wheelchair van run report, written by EMT #1 revealed, "U/A (upon arrival) @ (at) (Hospital A) pt (patient) in bed alert. Pt transferred to w/c (wheelchair), secured, loaded into wc (wheelchair) van, secured & transported to residence (address). U/A pt transferred to chair & secured."

Telephone interview conducted with Paramedic #1 on 03/01/2017 at 1145 revealed Patient #11 complained of right arm pain and right leg pain behind her upper thigh. Paramedic #1 could not recall whether or not Patient #11 could bear weight. Interview reveled when arriving at Hospital A, the receiving nurse is given a verbal patient report, and the complete run report is generally completed upon return to their station. Interview revealed, "The hospital gets a 'Reader's Digest' version of the run report prior to our departure, and unless requested otherwise, that is all the hospital gets."

Interview conducted with RN #1 on 03/02/2017 at 0945 revealed she did not recall Patient #11. RN #1 reported that according to hospital documentation, it did not appear that EMS reported Patient #11 complaining of leg pain. Interview could not reveal any explanation of the complaint of right arm pain in the triage note, and a pain scale rating of 0 (zero) upon triage. Interview revealed, "I wouldn't have put 0 if the patient reported pain."

Physician interview was conducted with MD #1 on 03/01/2017 at 0900. Interview revealed Patient #11 seemed coherent, but "ill" upon assessment. Patient #11 was complaining of right forearm pain. MD #1 advised he did not recall Patient #11 complaining of any lower extremity pain. Interview revealed this was verified by nurse documentation. Interview revealed it was never reported to MD #1 that Patient #11 had complained of lower extremity pain to EMS, and EMS run reports are not generally available to Hospital A's ED physicians at the time of physician assessment. Interview revealed range of motion assessments were performed on Patient #11's upper extremities, and anterior pressure assessments were performed on her hips, shoulders, elbows, and wrists; to which she did not report pain. MD #1 advised this was his normal assessment for fall patients. Interview revealed nurses follow protocols prior to physician assessment, and if the patient had reported pain, she would have gotten X-rays wherever pain was reported. Interview revealed there was no attempt to ambulate Patient #11 prior to her discharge.

Interview conducted with RN #2 on 03/01/2017 at 0935 revealed she did not recall Patient #11. According to the hospital record, there was no attempt to ambulate her prior to her discharge. Interview revealed sometimes ambulating a patient prior to discharge is attempted, and does not necessarily require a physician order. Interview revealed RN #2 could not recall where Patient #11 was reporting pain at the time of her discharge, and that information was not documented in the hospital record.

Telephone interview conducted on 03/01/2017 at 1232 with EMT #1 revealed he did not specifically remember Patient #11. EMT #1 advised a patient cannot be transported home by wheelchair van unless the patient can stand and pivot to get into a wheelchair, as there is only one staff member on the wheelchair van. Interview revealed if a patient cannot stand and pivot to get into a wheelchair, a different unit with additional personnel and a stretcher would have to be called to transport the patient.

Patient #11 was not stabilized prior to discharge from the emergency department on 8/22/2016 there was no documentation in the medical record to indicate the patient was able to ambulate prior to discharge

Record review revealed Patient #11 returned to Hospital A's DED on 08/24/2016. Review of provider documentation written by MD #2 on 08/24/2016 at 1610 revealed, "...History of Present Illness: 77-year-old female presents to the emergency department via... EMS complaining of hip pain. Patient reports Monday (08/22/2016) she was trying to get out of her recliner when her shoe got caught on the chair causing her to fall and injure her right hip. She was seen in the emergency department following the incident, and had an x-ray of her right arm/hand, right knee, right femur, and right lower leg; fracture noted to the right first metacarpal. Patient states she has not been ambulatory at any point since the incident, and following discharge from the emergency department was placed in her recliner, but unable to walk or get out of the chair. She has no other complaints at this time..." A hip x-ray was performed, which identified a "right femoral neck fracture." While in Hospital A's DED a chest x-ray was also performed. A radiology report, dictated by Radiologist #1 on 08/24/2016 at 1104, revealed, "...IMPRESSION... 2. Age-indeterminate and possibly acute right proximal humerus fracture with possible intertrochanteric extension and varus angulation..." Review revealed Patient #11 was admitted to Hospital A, and received surgical repair of her hip fracture. A Provider Note written by Hospitalist #1 on 08/28/2016 at 1321 revealed, "...HISTORY OF PRESENT ILLNESS: Patient seen to follow-up right hip fracture, postop day #3... Later on as told by nursing that the daughter had noticed that the patient seemed to not use her shoulder very well since this recent fall. Patient had not mentioned any pain in this area. However elected to order an x-ray at the request of the daughter and the nurse. The x-ray did in fact later show a fracture. Discharge was cancelled. Patient was to be evaluated by orthopedics..." Orthopedic consult recommended non-operative management of the shoulder fracture, and Patient #11 was discharged from Hospital A on 08/29/2016.

Physician interview was conducted with MD #2 on 03/01/2017 at 1000. Interview revealed a chest x-ray was ordered for Patient #11 as a pre-operative measure, and not based upon clinical presentation. Interview revealed, "Not all radiology reports are called to me unless radiology thinks it's something acute. It's really radiologist discretion. I don't think it (the shoulder fracture) was called. If it was I would have mentioned it in my note. It's obviously there, but the missed hip was focused on at the time. The treatment (for the shoulder fracture) would have been a sling. This patient was not placed in a sling, according to the record."

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