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Based on interview and record review, the facility failed to ensure compliance with the provisions in §CFR 489.24(d)(4-5), when the facility's policies and procedures were not implemented, for one of 20 sample patients (Patient 2), when Patient 2 was triaged (the process of sorting patients in an emergency setting to determine the urgency of their medical needs) 28 minutes after arrival at the Emergency Department.

This failure had the potential to result in a delay of care for Patient 2 and may cause harm to the patient.

Based on the interview and record review, the facility failed to ensure triage (the process of sorting patients in an emergency setting to determine the urgency of their medical needs) in the Emergency Department (ED) was completed timely in accordance with the facility's policy and procedure (P&P), for one of the 20 sample patients (Patient 2), when Patient 2 was triaged 28 minutes after arrival at the ED.

This failure had the potential to result in a delay of care for Patient 2 and may cause harm to the patient.

Findings:

On October 22, 2025, at 2:40 p.m., a concurrent interview and review of Patient 2's record were conducted with the Patient Safety Coordinator (PSC). A facility document titled, "[Name of facility] Emergency Provider Report," dated August 31, 2025, was reviewed. The document indicated Patient 2 was brought to the ED as a trauma tier 2 (two) alert (for patients with serious injuries or illness who might deteriorate or suffer long term medical problems if they do not receive treatment timely) after the patient had a partial crush injury (occurs when a body part is subjected to high force or pressure) on August 30, 2025, when a gate fell on Patient 2's right side and a horse stood on the gate.

On October 22, 2025, at 2:50 p.m., a facility document titled, "Emergency Patient Record," dated October 21, 2025, was reviewed. The document indicated, "...Stated Complaint: Right Wrist Pain...Chief Complaint: Trauma...Priority: 2 [for patient with serious illness or injury]...Status Event History...8/30/25 [August 30, 2025] 2128 [9:28 p.m.]...2151 [9:51 p.m.] Room Placement...2156 [9:56] APOD [Ambulance Patient Offload Delay, the main area where patients are seen and treated faster related to the level of care needed]...Assessments...Rapid Initial Assessment...Date...8/30/2025 [August 30, 2025] 2156 [9:56 p.m.]...Rapid Initial Assessment...First Point of Contact: Yes...Arrived by: WI [walk in]...SUBJECTIVE ASSESSMENT...Patients description of reason for visit: TRAUMA ALERT CAUSED BY METAL GATE AND HORSE...Onset of Symptoms Date: 8/30/2025 [August 30, 2025]..."

A review of an untitled and undated facility document was conducted. The document indicated, "...Arrival Date: 8/30/25...Arrival Time: 2128 [9:28 p.m.]...Triage Date: 8/30/25...Triage Time 2156 [9:56 p.m.]...Triage Level: 2 ...Placed in Bed Date 8/30/25...Placed in Bed Time: 2156 [28 minutes after Patient 2 arrived at the ED]..."

There was no documented evidence Patient 2 was triaged upon the patient's arrival in the ED.

On October 23, 2025, at 11:30 a.m., an interview was conducted with the ED Manager (EDM). The EDM stated Patient 2 was not triaged upon arrival to the ED. The EDM stated Patient 2 arrived on August 20, 2025, at 9:28 p.m., and was not triaged until 9:56 p.m. on Augutst 20, 2025. The EDM stated the facility's P&P to triage the patient upon arrival was not followed.

A review of facility P&P titled, "Patient care in the Emergency Department: Triage, Medical Screening Exam [MSE, a process performed by qualified medical personnel at a hospital's dedicated emergency department to determine if an individual has an emergency medical condition], and Patient Flow Until Discharge," dated October 23, 2024, was conducted. The P&P indicated, "...Triage...Patients...presenting to the Emergency Department will be triaged by a Registered Nurse...To assess each patient upon arrival in the department to determine priority of care and intervention required...To recognize the patient who needs immediate intervention and to provide such in order to save life or limb...patients status will be evaluated and prioritized..."