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Based on interview and record review, the CAH (Critical Access Hospital) failed to ensure complete and accurate documentation of the Emergency Department (ED) medical record for 2 of 20 records in the total sample. (Patients #10,13 )Findings include:

1. Per record review on 9/10/12, Patient #13 (age 7) was brought to the ED on 9/3/12 after sustaining a finger amputation while using a log splitter. Due to the nature of the injury and the psychosocial component which developed during the care of the patient, a request was made to have a staff social worker assist with managing the case and the logistic of transferring the patient to a tertiary hospital. Difficulties arose regarding parental consent, mode of transfer, identifying who would accompany Patient #13 when transferred via helicopter, however the nursing notes did not reflect a social service consultation or the ongoing issues surrounding care and services while the patient received treatment in the ED. Per CAH policy Emergency Department Nursing Standards of Care effective date 6/16/11 states: Psychosocial support is provided as well as consultations to appropriate resources such as social services, Chaplin or psychiatric services. These consultations should be documented in the nursing documentation." The incomplete documentation was confirmed on the afternoon of 9/11/12 by the Vice President of the Hospital Division.

2. Per record review on 9/10/12, the Triage Nursing Assessment for Patient #10, dated 6/7/12 at 2015 hours, included no documentation regarding an initial pain assessment related to a reported finger injury and no initial blood pressure reading. The patient, who was 11 years old, was later diagnosed with a fracture of the proximal phalanx of the right 5th finger. The 'Discharge Care and Disposition' section of the triage assessment included no documentation in the vital signs area and a pain level documented as 5 out of 10, which is above minimal pain. Per review of the hospital's policy/procedure entitled "Emergency Department Nursing Standards of Care" under B. Subjective/Objective Assessment, 5. "Assessment of physical pain will be included in the initial assessment of all patients, using the 0 - 10 numeric pain distress Scale for Adults, the FLACC (non-verbal) for ages >3 and the Faces Rating Scale for children 3-7 years old". Additionally, under B.1.f. "Complete vital signs are taken for all patients" (includes all patients >5 years of age).
The nurse's failure to completely document all areas of the triage assessment was confirmed during interview with the Vice President of Hospital Services and the Director of Quality Assurance (QA) on 9/11/12 at 4:30 PM.

Based on interview and record review, the CAH failed to ensure properly executed informed consent for transfer from the CAH to another facility for 3 applicable patients. (Patients # 7, 13, 17 ) Findings include:

1. Per record review on 9/10/12, Patient #13 required transfer to a tertiary facility due to a finger amputation. The CAH "Transfer Form" lacked required documentation to include:
next of kin/legally responsible person with their phone number; transfer consent signatures were not obtained (Patient #13 was a minor); the name of the facility where the patient was transferred and who accompanied the patient during the transfer. The omissions were confirmed with the VP of the Hospital Division on the afternoon of 9/11/12.


2. Per review on 9/10/12, the patient "Transfer Forms" for Patients #7 and #13 were incompletely documented in all required sections. The section for identification of the next of kin/legally responsible person(s) including contact information, was left blank for both of these patients. Patients #7 and #13 were each transferred from the hospital's Emergency Department (ED) to a tertiary care hospital for needed treatment.
The failure to complete the Patient Transfer Forms was confirmed during interview with the VP of Hospital Division and the Director of QA on 9/11/12 at 4:30 PM.

Based on interview and record review, the CAH Emergency Department quality assurance program failed to identify the limitations of the present process of posting the "Call Schedule" for only a 24 hour period within the Emergency Department. As a result, ED providers lack the ability to appropriately refer a patient for timely consultations and/or follow-up treatment with a specialists. Findings include:

Per record review on 9/10/12, Patient #2, who sustained a thumb injury while playing soccer, was brought to the ED for treatment by his/her parent on 8/17/12. The patient was examined by the ED physician, and after x-rays was diagnosed with a fracture of the left thumb. The ED physician applied a thumb spica splint, wrap and casting material and provided a referral to the CAH orthopedic surgeon noting the patient should be seen within 3-4 days. The patient's injury was on Friday, the parents preceded to contact the orthopedic surgeons office on Monday 8/20/12 for follow up/consultation. After multiple phone calls, the parents were informed the orthopedic surgeon was not available for the entire week and another orthopedic surgeons office was also not providing appointments. Eventually, the patient was seen at a tertiary facility on the 5th day after his/her injury after obtaining a referral from Patient #2's pediatrician and required surgery the following day. Per interview on 9/11/12 at 11: 42 AM, the ED physician who treated Patient #2 on 8/17/12 stated the on-call list is only posted for each 24 hour period and s/he was unaware the orthopedic physician was not available to see and treat Patient #2 on the following Monday 8/20/12. If the full schedule for the month had been posted and available s/he would have not referred Patient #2 to the CAH orthopedic surgeon, and a referral to a tertiary hospital orthopedic service would have been made.