HospitalInspections.org

Based on record review, review of facility policies and staff interviews. The facility failed to follow their policy regarding providing stabilizing treatment within the facilities capabilities for 1 patient (P) (P2) of 20 sampled medical records. This failed practice has the potential to cause permanent harm or even death to all patients that present to the Emergency Department (ED) for evaluation of an emergency medical condition (EMC). According to facility provided information the ED treats on average 79 patients per month.
See citation C2407, that also resulted in C2400 to not be met.

Based on review of CAH-A's medical records, ACF-B medical record reviews, facility policy review and CAH-A's database information the CAH failed to provide stabilizing care to 1 (P2) of 20 medical records sampled that were treated for an EMC in the ED. This failed practice has the potential to cause permanent harm or even death to all patients that present for treatment to the ED. According to facility provided information the ED treats around 79 patients per month.

Also see C2400 and C2406 that resulted in C2407 not being met.

Findings include:

A. Review of facility policy "EMTALA - Medical Evaluation and Patient Transfers", approved 7/18/23 revealed, an emergency medical condition (EMC) is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbance and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the health of the individual in serious jeopardy
- Serious impairment to bodily function, or
- Serious dysfunction of any bodily organ or part
Stabilize: To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during transfer of the individual from a facility.
Further Examination and Treatment: If the individual has an EMC, further medical examination, and stabilizing treatment within the capabilities of the staff and facilities must be provided.

B. Review of the facility database completed by the Chief Executive Officer (CEO) of CAH-A and reviewed with surveyor revealed, CAH-A is a 15-bed licensed facility. Certified as a Basic Trauma Facility (level 4). To be certified as a Basic Trauma Facility all ED Registered Nurses (RNs) must have current Trauma Nurse Core Course (TNCC) certification and ED medical providers must have current Advanced Trauma Life Support class (ATLS) certification. The facility employs 13 full time RNs, 1 full time physician, 2 full time physician assistants (PAs), and 2 Nurse Practitioners (NP) all who provide ED coverage. The CAH is also contracted with a telehealth emergency service that is available 24 hours a day, 7 days a week. Any provider or nurse can connect with the service when needed.

C. Review of CAH-A's medical record revealed, P2 presented to the ED on 7/16/23 at 4:23PM via EMS following a SUV versus semi MVC. P2's SUV was traveling at a speed of 50 miles per hour when it ran into the back of a parked semi. The SUV was noted to have significant damage to the front end. P2 was the unrestrained (not wearing seatbelt) driver, the windshield was starred (indicates passenger impact) on the driver's side. EMS had P2 in a c-collar, K.E.D, backboard and headblocks for spinal immobilization. Upon arrival to ED EMS reported that P2 had complaints of bilateral upper extremities tingling and unable to move them at scene prior to extrication of the vehicle. Upon arrival to the primary and secondary trauma assessments were completed with it noted that P2 did not have purposeful extremity movements and was unable to move bilateral upper extremities, normal sensation distal to spinal cord injury and diminished motor distal to spinal cord injury. With hand grasps being unable to obtain due to patient condition. At 4:48 PM MD-A removed immobilization (K.E.D and backboard) with log roll and posterior inspection with no abnormalities noted. CT of head, c-spine, neck, chest, abdomen, and pelvis were completed.

CT results were reviewed with P2 and spouse at 6:07 PM. MD-A then removed the c-collar. RN-B noted that CMS intact in lower extremities and not change in movement of bilateral arms, sensory and pulses good in upper extremities intact after removal of c-collar. At 6:55 PM MD-A at bedside discussing the plan of care. Plan was to observe P2 in the ED for a period of time to ensure P2 could void (urinate) after being straight cathed for urine sample and be able to get up and ambulate. After P2 failed to be able to urinate (could indicate a possible spinal injury) and was also unable to stand without leaning to the left and needing an assist of 3 to stand and transfer to a bedside commode. P2 also had a change in CMS assessment of being unable to walk, difficulty moving bilateral legs, unable to move bilateral upper extremities decision to transfer was made.

RN-B documented P2's pain through out the shift. Initial pain assessment was completed with initial vital signs at 4:35 PM with pain rating 8/10. Pain rating at 5:19 PM 10/10. P2 was given IV Tylenol at 5:23 PM. At 6:00 PM pain rating 9/10. MD-A was notified of pain rating and stated that he would not be giving any additional pain medication until the CT results were back. Results of CT were reviewed with P2 at 6:07 PM. The record lacks documentation of pain medication being ordered after CT results were received. At 7:00PM pain rating is documented as 10/10. RN-B again notified MD-A of pain being uncontrolled. MD-A stated that he wanted to hold off on pain medication at this time. RN-C took over care at 7:25 PM. At 9:50 PM RN-C documented pain as 8/10. Oral Tylenol 650mg was given at 9:00PM. P2's pain was reassessed after Tylenol at 10:15PM pain ratine 8/10. At this time P2 was given oral Percocet 5/325milligrams (mg) 2 tablets. P2's pain rating at 12:20AM prior to transfer continued to be 8/10.

D. Review of ACH-B's medical records revealed P2 was transferred from CAH-A to ACH-B for increased changes in P2's neurological exam after MVC. P2's CT's done at CAH-A were noted to have no acute findings. P2 endorsed fentanyl given during air transport made a big difference in decreasing P2's pain. P2 had an MRI done after arrival to ACH-B. Neurosurgery reviewed MRI and recommended transfer to a higher level of care for decompressive surgery and postoperative physical therapy. ACH-B transferred P2 to ACF-D for further treatment.