HospitalInspections.org

Based on hospital EMTALA policy review, medical record reviews, physician and staff interviews, the hospital failed to comply with 42 CFR §489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases and the related requirements at §489.20 (l), (m), (q), and (r), which pertain to the Federal Emergency Medical Treatment and Labor Act (EMTALA).

Findings included:

1. Based on hospital EMTALA policy reviews, medical record reviews, on call schedules review, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services of laboratory studies that are routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 25 sampled DED patients (#7) who presented to the hospital for evaluation and treatment for complaint of shortness of breath.
~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A-2406.

2. The hospital's Dedicated Emergency Department (DED) physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 25 sampled patients (#7) who presented to the hospital's DED with an Emergency Medical Condition (EMC) and were discharged or transferred to other acute care hospitals.
~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment - Tag A-2407.

Based on hospital EMTALA policy reviews, medical record reviews, on- call schedule reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physicians failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services (on-call vascular surgery) that are routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 (#7) of 25 sampled DED patients who presented to the hospital for evaluation and treatment.

Findings included:

The facility's policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Compliance", Policy Code PR-ED, 2012 -63 was reviewed. The policy revealed in part, "To establish the procedure by which individuals seeking or requiring emergency care are appropriately
screened, examined, stabilized, treated, and/or transferred ... DEFINITIONS: o Capability: The organization has the facility, staff, and equipment necessary to provide the
requested medical service ... Emergency medical Condition (EMC) A condition manifesting symptoms (including severe pain ...) that in the absence of immediate medical attention, are likely to cause serious dysfunction or impairment to a bodily organ or function or serious jeopardy to the health of the individual ... Procedure: Medical Screening Examination (MSE) 1. Any individual that presents to ...DED (Dedicated Emergency Department) or hospital property and requests examination or treatment ...will be provided a medical screening examination (MSE) to determine if an emergency medical condition exists. 2. The MSE will be performed within the capability and capacity of the hospital, including ancillary services, resources routinely available, and on-call providers as indicated."

A review of the Facility's on call Vascular Surgery schedule revealed that on 9/9/2017 and 9/10/2017 a vascular surgeon was on call when Patient #7 presented the hospital's emergency department.


Review of the closed DED medial record on 03/14/2018 for Patient #7 (Visit #2) revealed a 48-year-old female that presented to the DED on 09/09/2017 at 0929 with a chief complaint of left foot pain. Review of triage nursing notes documented at 0935 revealed " Pt to ed (emergency department) with c/o (complaint of) left foot pain x (times) several days. Report stent placement in Jan by dr. (name). " Review of vital signs revealed Patient #7 was afebrile with a temperature of 98.7 and a negative sepsis screening. Review of a nursing note revealed " Pt states she has left foot pain for 2 weeks, states she had a cast removed yesterday (09/08/2017) and a boot placed, states she had her left big toe amputated in December, pt is NWB (non-weight bearing) on left foot. " Patient medical record showed the patient had a medical screening completed by MD #2 at 1100. Record review revealed a lactic acid, basic metabolic panel, (a group of blood
tests gives information about the body's metabolism) Blood Urea Nitrogen 24 H (High); Creatinine 1.41 H(Hospital reference range 0.44-1.00 ); and Glucose 366 (hospital reference range 65-99), and complete blood count with differential/platelet. A left complete foot x-ray dated 9/9/2017 Impression revealed in part, " ...2. Re-demonstrated the second metatarsal extending to involve the second TMT joint, potentially indicative of as erosive arthopathy, through septic arthritis, could result in a similar appearance. Further evaluation of the foot with MRI could be performed as indicated. 3. Potential subcutaneous Emphysema about the proximal phalanx of the fourth digits without foreign body or discrete area of osteolysis. Again further evaluation with MRI would be performed as indicated". An intravenous access and Dilaudid (pain medication) 1 milligram were ordered at 1105. Review of nursing notes revealed intravenous access attempted without success and patient consented to access her port at 1135. Review of provider notes documented at 1254 revealed " ...with multiple different medical problems including anemia, port, CHF (Congested Heart Failure), depression, angina, diabetes mellitus, poor peripheral circulation, status post stent in 2016 who presents today with ongoing and worsening pain in her left foot. Pain is (sic) been there for 2-3 weeks. She did see Dr. Name (Podiatrist) is (sic) closely being watched by him. She takes Percocet but is about run out (sic). She states that the pain has been constant. Nothing makes it better nothing makes it worse. She has some darkening to her toes and under her fourth toe there is a small fissure. She has not followed up as instructed with vascular surgery since her procedure. She does however follow with podiatry. Patient is here for pain control. She denies any other acute decompensation last several weeks (sic). PHYSICAL EXAM: ...Musculoskeletal: Patient ' s right lower extremity is nontender and warm with good pulses left lower extremity has strong Doppler pulses in (sic) faint pulses to palpation, it is warm and well perfused. There is some darkening to the third and fourth toe particularly with a small fissure noted underneath the fourth toe with no evidence of gangrenous changes, it is not purulent not red not hot to touch and there is no crepitus noted. ...INITIAL IMPRESSION / ASSESSMENT AND PLAN / ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me and considered in my medical decision making ...Patient here since it (sic) pain control for chronic claudication all issues. I discussed with Dr. Name (Vascular Surgeon) who agrees with management advised the patient continue her home medications and follow-up with him closely. There is no evidence despite radiology reading of an acute gangrenous or gas gangrene process. I believe that we are seeing on that x-ray is that small fissure underneath the toe which is trapping small amounts of air but there is no evidence that it is an acute or active infection at this time. Patient is otherwise quite well-appearing lactic is negative. Her kidney function is somewhat elevated she states she has not been eating and drinking very well recently second to the pain. We will give her IV fluid bolus here. She ' ll follow closely with primary care doctor for recheck. We will ensure that she has adequate pain control until that time. After Dilaudid, patient is very calm and she has no discomfort. Extensive return precautions and follow-up instructions given and understood. "Review of medical record revealed Dilaudid 1 milligram was administered at 1206 and Normal Saline 500 milliliters administered at 1313. Review of provider notes documented at 1330 revealed " Patient is made aware that she must not drive after Dilaudid. She remains comfortable here. I think most probably a large contributing reason for this visit is the fact that she is about out of her pain medication although clinically there is a (sic) ischemic issue as well. The patient will follow closely as an outpatient. She states she is compliant with her Plavix and aspirin. Return precautions given and understood. Patient does have a mild bump in her liver function test. She states the pain has made it that she has not had much to eat or drink recently, we are giving her IV fluids here and she understands she must have cr (creatinine) and foot rechecked in the next day or 2 by primary which she states she will do. " Review of physician discharge orders revealed Patient #7 was given a prescription for oxycodone-acetaminophen 5-325 milligrams. Record review revealed Patient #7 was discharged at 1422.

Review of the closed DED medial record on 03/14/2018 for Patient #7 (Visit #3) revealed a 48-year-old female that presented to the DED on 09/10/2017 at 2114 with a chief complaint of left foot pain. Review of triage nursing notes documented at 2120 revealed " Pt brought in via ems to triage in a wheelchair. Pt crying. Pt has left foot pain. Pt states she had great toe amputated in December 2016. Now pt has pain and color change to left 4th toe. Pt also has drainage. Pt states she has diabetes. " Review of vital signs revealed Patient #7 presented with a temperature of 99.3, heart rate 100, respiratory rate 22 and blood pressure of 167/82 at 2121. Record review showed a negative sepsis screening at 2123. Repeat vital signs documented at 2142 revealed heart rate decreased to 87, respiratory rate 22 and blood pressure 181/92. Patient #7 ' s medical record showed the patient had a medical screening completed by MD #3 at 2328. Review of provider notes documented at 2328 revealed " ...who comes into the hospital today with foot pain. The patient reports she ' s been here twice this weekend and is having shooting pain from the bottom of her knee to her foot. She reports that one of her toes is also turning black. She reports that she ' s had an infection in the past and she is very concerned might get worse. She reports that she ' s been going to the podiatrist for the past 3 weeks when she had the pain in the evening put her in a boot but it has not been helping. She reports that she ' s been sent home with pain medicine does not help her. Her foot is killing her and she rates her pain a 10 out of 10 in intensity. She reports that she doesn ' t know what ' s going on and does not remember what she was told to do. She has an appointment with Dr. Name (vascular surgeon) on Thursday and has had a stent in that leg in the past. She reports that the toe started going back (sic) about 3 days ago. She ' s been putting antibiotic cream in there and reports that nothing is helping. She denies any fevers but does have some nausea and vomiting which she reports is not abnormal for her given her gastroparesis. She reports that she is very concerned about this and does not want to wait too long. She reports that she does not want to go home until she has some answers as to what ' s going on with her foot. The patient is here for reevaluation. ...INITIAL IMPRESSION / ASSESSMENT AND PLAN / ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me and considered in my medical decision making ...comes into the hospital today with some foot pain. The patient has a history of peripheral vascular disease and diabetes. She had had a (sic) in this leg in the past. I will check some blood work again as well as some (sic) the patient for an x-ray looking for some signs of osteomyelitis. The patient will be reassessed. She did receive a dose of Dilaudid for her pain. Clinical Course: DG Foot Complete Left 1. Probable fourth proximal phalangeal soft tissue gas. Suspicious for soft tissue abscess and/or osteomyelitis although no frank bony destruction is visible to confirm. 2. Erosive changes at the base of the second metatarsal could represent osteomyelitis, septic arthritis, erosive arthropathy. This is not significantly changed. 3. Foot MRI (Magnetic Resonance Imaging scan) would be helpful for optimal characterization. After seeing the patient ' s x-ray I was concerned for possible osteomyelitis. I did check a sedimentation rate which is elevated. I will order an MRI to evaluate the patient ' s foot. The patient ' s care will be signed out to Dr. Name (MD #1) who will follow up the result of the MRI and disposition the patient. " Record review revealed a lactic acid, blood culture x 2, basic metabolic panel, complete blood count and Dilaudid (pain medication) 1 milligram were ordered at 2353. Review of nursing notes revealed intravenous access inserted on 09/11/2017 at 0022. Review of medical record revealed Dilaudid 1 milligram was administered on 09/11/2017 at 0023. Record review revealed an order for a left complete foot x-ray ordered on 09/11/2017 at 0122. Further review of the medical record revealed an order for a sedimentation rate and Vancomycin (antibiotic) 1000 milligrams was placed on 09/11/2017 at 0334. Review of nursing notes revealed Vancomycin 1000 milligrams was administered intravenously at 0409. Review of lab results documented at 0422 revealed sedimentation rate was 74 (reference range 0-20). Review of physician orders dated 09/11/2017 at 0551 revealed an order for Dilaudid 1 milligram intravenously for pain. Nursing notes revealed Dilaudid 1 milligram was administered at 0559. Medical record revealed a physician order by MD #3 at 0610 for a MRI (Magnetic Resonance Imaging) scan of left foot with and without contrast. Further review of the medical record revealed the MRI order was modified as Left foot without contrast by MD #1 on 09/11/2017 at 0834. Nursing notes revealed Patient #7 was administered Dilaudid 1 milligram intravenously at 0851. Review of MD #1 ' s provider note dated 09/11/2017 at 1034 revealed MRI " Impression: 1. Soft tissue emphysema within the fourth toe suggested on earlier radiographs is not definitely confirmed by this examination which is limited by motion. 2. Nonspecific forefoot soft tissue edema, likely due to cellulitis and myositis. No focal fluid collections. 3. No findings suspicious for osteomyelitis. Probable Charcot (weakening of the foot bones) changes at the Lisfranc joint (connects foot bones to arch bones), similar to prior radiographs. Patient was (sic) Charcot changes in her foot. She can will (sic) continue outpatient follow-up with vascular surgery and podiatry. " Review of MD #1 ' s discharge instructions revealed documentation for Patient #7 to follow-up with her vascular surgeon and podiatrist as soon as possible for recheck. Review of nursing discharge notes at 1120 revealed Patient #7 " No/denies pain (pt crying at d/c (discharge) but denied pain. Reports she is ' scared her toe is going to rot off ' ). Record review revealed Patient #7 was discharged on 09/11/2017 at 1120.

Interview on 03/15/2017 at 1045 with MD #1 revealed he was the physician who assumed cared of Patient #7 on 09/11/2017 at 0700 and reported off care of Patient #7 to MD #4 on 09/18/2017 at 2040. Interview revealed he reviewed the results of the MRI performed on 09/11/2017 and stated he did not identify any evidence of osteomyelitis or on-going infection. Interview revealed he discussed the MRI results with the vascular surgeon and the podiatrist. Interview revealed MD #1 felt the blackened toes were an indication of vascular problem rather than infection. He stated Patient #7 was being followed by podiatry and vascular surgery. Interview revealed MD #1 discharged the patient with instructions to follow-up with podiatry and vascular surgeon. He stated " she seemed okay with going home. " Further interview revealed he completed the initial MSE for Patient #7 on 09/18/2017 and signed out her care to MD #4 at the end of his shift. He stated he prescribed pain medications and called the vascular surgeon for consult. Interview revealed the vascular surgeon recommended patient continue with outpatient follow-up and keep appointment for angiogram scheduled on 09/21/2017. He stated the patient had a low-grade fever upon arrival, but later spiked a fever of greater than 101, with increased heart rate and a decision to admit the patient was made by MD #4.

The facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital for patient #7 on 9/9/2017 and 9/10/2017.

Based on hospital medical record reviews, on- call schedule review, staff and physician interviews the hospital's Dedicated Emergency Department (DED) physicians failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 25 sampled patients (#7) who presented to the hospital's DED with an Emergency Medical Condition (EMC) and was discharged or transferred to other acute care hospitals.

Findings included:

Review of the closed DED medial record on 03/14/2018 for Patient #7 (Visit #2) revealed a 48-year-old female that presented to the DED on 09/09/2017 at 0929 with a chief complaint of left foot pain. Review of triage nursing notes documented at 0935 revealed " Pt to ed (emergency department) with c/o (complaint of) left foot pain x (times) several days. Report stent placement in Jan by dr. (name). " Review of vital signs revealed Patient #7 was afebrile with a temperature of 98.7 and a negative sepsis screening. Review of a nursing note revealed " Pt states she has left foot pain for 2 weeks, states she had a cast removed yesterday (09/08/2017) and a boot placed, states she had her left big toe amputated in December, pt is NWB (non-weight bearing) on left foot. " Patient medical record showed the patient had a medical screening completed by MD #2 at 1100. Record review revealed a lactic acid, basic metabolic panel, complete blood count with differential/platelet, left complete foot x-ray, intravenous access and Dilaudid (pain medication) 1 milligram were ordered at 1105. Review of nursing notes revealed intravenous access attempted without success and patient consented to access her port at 1135. Review of provider notes documented at 1254 revealed " ...with multiple different medical problems including anemia, port, CHF (Congested Heart Failure), depression, angina, diabetes mellitus, poor peripheral circulation, status post stent in 2016 who presents today with ongoing and worsening pain in her left foot. Pain is (sic) been there for 2-3 weeks. She did see Dr. Name (Podiatrist) is (sic) closely being watched by him. She takes Percocet but is about run out (sic). She states that the pain has been constant. Nothing makes it better nothing makes it worse. She has some darkening to her toes and under her fourth toe there is a small fissure. She has not followed up as instructed with vascular surgery since her procedure. She does however follow with podiatry. Patient is here for pain control. She denies any other acute decompensation last several weeks (sic). PHYSICAL EXAM: ...Musculoskeletal: Patient ' s right lower extremity is nontender and warm with good pulses left lower extremity has strong Doppler pulses in (sic) faint pulses to palpation, it is warm and well perfused. There is some darkening to the third and fourth toe particularly with a small fissure noted underneath the fourth toe with no evidence of gangrenous changes, it is not purulent not red not hot to touch and there is no crepitus noted. ...INITIAL IMPRESSION / ASSESSMENT AND PLAN / ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me and considered in my medical decision making ...Patient here since it (sic) pain control for chronic claudication all issues. I discussed with Dr. Name (Vascular Surgeon) who agrees with management advised the patient continue her home medications and follow-up with him closely. There is no evidence despite radiology reading of an acute gangrenous or gas gangrene process. I believe that we are seeing on that x-ray is that small fissure underneath the toe which is trapping small amounts of air but there is no evidence that it is an acute or active infection at this time. Patient is otherwise quite well-appearing lactic is negative. Her kidney function is somewhat elevated she states she has not been eating and drinking very well recently second to the pain. We will give her IV fluid bolus here. She ' ll follow closely with primary care doctor for recheck. We will ensure that she has adequate pain control until that time. After Dilaudid, patient is very calm and she has no discomfort. Extensive return precautions and follow-up instructions given and understood. " Review of medical record revealed Dilaudid 1 milligram was administered at 1206 and Normal Saline 500 milliliters administered at 1313. Review of provider notes documented at 1330 revealed " Patient is made aware that she must not drive after Dilaudid. She remains comfortable here. I think most probably a large contributing reason for this visit is the fact that she is about out of her pain medication although clinically there is a (sic) ischemic issue as well. The patient will follow closely as an outpatient. She states she is compliant with her Plavix and aspirin. Return precautions given and understood. Patient does have a mild bump in her liver function test. She states the pain has made it that she has not had much to eat or drink recently, we are giving her IV fluids here and she understands she must have cr (creatinine) and foot rechecked in the next day or 2 by primary which she states she will do. " Review of physician discharge orders revealed Patient #7 was given a prescription for oxycodone-acetaminophen 5-325 milligrams. Record review revealed Patient #7 was discharged at 1422.

Review of the closed DED medial record on 03/14/2018 for Patient #7 (Visit #3) revealed a 48-year-old female that presented to the DED on 09/10/2017 at 2114 with a chief complaint of left foot pain. Review of triage nursing notes documented at 2120 revealed " Pt brought in via ems to triage in a wheelchair. Pt crying. Pt has left foot pain. Pt states she had great toe amputated in December 2016. Now pt has pain and color change to left 4th toe. Pt also has drainage. Pt states she has diabetes. " Review of vital signs revealed Patient #7 presented with a temperature of 99.3, heart rate 100, respiratory rate 22 and blood pressure of 167/82 at 2121. Record review showed a negative sepsis screening at 2123. Repeat vital signs documented at 2142 revealed heart rate decreased to 87, respiratory rate 22 and blood pressure 181/92. Patient #7 ' s medical record showed the patient had a medical screening completed by MD #3 at 2328. Review of provider notes documented at 2328 revealed " ...who comes into the hospital today with foot pain. The patient reports she ' s been here twice this weekend and is having shooting pain from the bottom of her knee to her foot. She reports that one of her toes is also turning black. She reports that she ' s had an infection in the past and she is very concerned might get worse. She reports that she ' s been going to the podiatrist for the past 3 weeks when she had the pain in the evening put her in a boot but it has not been helping. She reports that she ' s been sent home with pain medicine does not help her. Her foot is killing her and she rates her pain a 10 out of 10 in intensity. She reports that she doesn ' t know what ' s going on and does not remember what she was told to do. She has an appointment with Dr. Name (vascular surgeon) on Thursday and has had a stent in that leg in the past. She reports that the toe started going back (sic) about 3 days ago. She ' s been putting antibiotic cream in there and reports that nothing is helping. She denies any fevers but does have some nausea and vomiting which she reports is not abnormal for her given her gastroparesis. She reports that she is very concerned about this and does not want to wait too long. She reports that she does not want to go home until she has some answers as to what ' s going on with her foot. The patient is here for reevaluation. ...INITIAL IMPRESSION / ASSESSMENT AND PLAN / ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me and considered in my medical decision making ...comes into the hospital today with some foot pain. The patient has a history of peripheral vascular disease and diabetes. She had had a (sic) in this leg in the past. I will check some blood work again as well as some (sic) the patient for an x-ray looking for some signs of osteomyelitis. The patient will be reassessed. She did receive a dose of Dilaudid for her pain. Clinical Course: DG Foot Complete Left 1. Probable fourth proximal phalangeal soft tissue gas. Suspicious for soft tissue abscess and/or osteomyelitis although no frank bony destruction is visible to confirm. 2. Erosive changes at the base of the second metatarsal could represent osteomyelitis, septic arthritis, erosive arthropathy. This is not significantly changed. 3. Foot MRI (Magnetic Resonance Imaging scan) would be helpful for optimal characterization. After seeing the patient ' s x-ray I was concerned for possible osteomyelitis. I did check a sedimentation rate which is elevated. I will order an MRI to evaluate the patient ' s foot. The patient ' s care will be signed out to Dr. Name (MD #1) who will follow up the result of the MRI and disposition the patient. " Record review revealed a lactic acid, blood culture x 2, basic metabolic panel, complete blood count and Dilaudid (pain medication) 1 milligram were ordered at 2353. Review of nursing notes revealed intravenous access inserted on 09/11/2017 at 0022. Review of medical record revealed Dilaudid 1 milligram was administered on 09/11/2017 at 0023. Record review revealed an order for a left complete foot x-ray ordered on 09/11/2017 at 0122. Further review of the medical record revealed an order for a sedimentation rate and Vancomycin (antibiotic) 1000 milligrams was placed on 09/11/2017 at 0334. Review of nursing notes revealed Vancomycin 1000 milligrams was administered intravenously at 0409. Review of lab results documented at 0422 revealed sedimentation rate was 74 (reference range 0-20). Review of physician orders dated 09/11/2017 at 0551 revealed an order for Dilaudid 1 milligram intravenously for pain. Nursing notes revealed Dilaudid 1 milligram was administered at 0559. Medical record revealed a physician order by MD #3 at 0610 for a MRI (Magnetic Resonance Imaging) scan of left foot with and without contrast. Further review of the medical record revealed the MRI order was modified as Left foot without contrast by MD #1 on 09/11/2017 at 0834. Nursing notes revealed Patient #7 was administered Dilaudid 1 milligram intravenously at 0851. Review of MD #1 ' s provider note dated 09/11/2017 at 1034 revealed MRI " Impression: 1. Soft tissue emphysema within the fourth toe suggested on earlier radiographs is not definitely confirmed by this examination which is limited by motion. 2. Nonspecific forefoot soft tissue edema, likely due to cellulitis and myositis. No focal fluid collections. 3. No findings suspicious for osteomyelitis. Probable Charcot (weakening of the foot bones) changes at the Lisfranc joint (connects foot bones to arch bones), similar to prior radiographs. Patient was (sic) Charcot changes in her foot. She can will (sic) continue outpatient follow-up with vascular surgery and podiatry. " Review of MD #1 ' s discharge instructions revealed documentation for Patient #7 to follow-up with her vascular surgeon and podiatrist as soon as possible for recheck. Review of nursing discharge notes at 1120 revealed Patient #7 " No/denies pain (pt crying at d/c (discharge) but denied pain. Reports she is ' scared her toe is going to rot off ' ). Record review revealed Patient #7 was discharged on 09/11/2017 at 1120.

Interview on 03/15/2017 at 1045 with MD #1 revealed he was the physician who assumed cared of Patient #7 on 09/11/2017 at 0700 and reported off care of Patient #7 to MD #4 on 09/18/2017 at 2040. Interview revealed he reviewed the results of the MRI performed on 09/11/2017 and stated he did not identify any evidence of osteomyelitis or on-going infection. Interview revealed he discussed the MRI results with the vascular surgeon and the podiatrist. Interview revealed MD #1 felt the blackened toes were an indication of vascular problem rather than infection. He stated Patient #7 was being followed by podiatry and vascular surgery. Interview revealed MD #1 discharged the patient with instructions to follow-up with podiatry and vascular surgeon. He stated " she seemed okay with going home. " Further interview revealed he completed the initial MSE for Patient #7 on 09/18/2017 and signed out her care to MD #4 at the end of his shift. He stated he prescribed pain medications and called the vascular surgeon for consult. Interview revealed the vascular surgeon recommended patient continue with outpatient follow-up and keep appointment for angiogram scheduled on 09/21/2017. He stated the patient had a low-grade fever upon arrival, but later spiked a fever of greater than 101, with increased heart rate and a decision to admit the patient was made by MD #4.

A review of the hospital's on call vascular surgery (capability) revealed that on 9/9/2017 and 9/10/2017 a vascular surgeon was available to provide further evaluation and treatment when Patient #7 presented to the ED.


The facility failed to ensure that stabilizing treatment was provided that was within the capability , staff and facility that were available at the hospital for further evaluation and treatment as required to stabilize Patient #7's emergency medical condition, instead the patient was discharged home.