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Based on record review and interview, the facility failed to ensure that a registered nurse with training and experience in emergency care trauma is utilized to conduct specific medical screening examinations for 1 (S#4) of 3 (S#s 3,4 and 5) records reviewed. This deficient practice may result in patients receiving inadequate assessment and treatment during their visit in the Emergency Department. The findings are:

A. Record review of the facility "Job Description for an ED RN (emergency department registered nurse) dated 10/01/2010 revealed that nurses are required to have BLS (Basic Life Support), ACLS ( Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support), and TNCC (Trauma Nursing Core Course) certifications.

B. Record review of S#4's Registered Nurse (RN) personnel file revealed there was no evidence that she is TNCC certified.

C. Record review of P#1's ED Record revealed that S#4 was the primary nurse who took care of P#1 during his stay in the ED.

D. On 10/16/19 at 4:00pm, during interview, S#7 DPCS ( Director of Patient Care Services) confirmed that there is no TNCC certification filed on S#4' personnel record. This is further verified on a follow-up email received from S#7 on 10/21/19 at 11:13 am stating that S#4 " was unable to locate her most recent TNCC certification".

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Based on record review and interview, the facility failed to establish procedure and proper coordination and communication with the emergency response providers on 1 (P#3) of 10 records reviewed to ensure patients are referred to appropriate locations for treatment. This failed practice has the potential to cause further harm or injury to patients requiring immediate care in an emergency situation. The findings are:

A. Record review of P#3's "ED record final" dated 06/27/19 revealed, diagnoses of fracture of the left tibia (also known as the shinbone or shankbone, is the larger and stronger of the two bones in the leg below the knee, and it connects the knee with the ankle bones), fracture of the left femur shaft (also known as broken thighbone, is the breakage of the shaft of the femur or thighbone), traumatic compartment syndrome left lower extremity (a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space), traumatic pneumothorax (abnormal presence of air in the pleural cavity resulting in the collapse of the lung), pneumomediastinum (a condition in which air is present in the mediastinum -the space in the chest between the two lungs), motorcycle driver injured in collision with other motor vehicles in traffic accident, right leg injury unspecified, hemoperitoneum (the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency).

B. Record review of P#3's chart on 10/16/19 revealed no documentation of the reason why the immediate transfer to an appropriate trauma center was delayed for three hours. P#3's chart revealed that P#3 arrived at the Emergency Department (ED) at 7:51 pm and was not transferred to a Level 1 Trauma Center until 10:52 pm. (Level 1 trauma Center is a facility that provides 24-hour in-house coverage by general surgeons, and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care)

C. On 10/16/19 at 11:00 am during interview, S#7 Director of Patient Care Services (DPCS) verified that there was no documentation in the chart reviewed as to what transpired during the three hour delay of the transfer to a Level 1 Trauma Center.

D. Record review of an email received from S#7 DPCS dated 10/21/2019, for an after the fact explanation of why transfer of P#3 to Level I Trauma Center was delayed revealed the reason from S#5, Registered Nurse (RN) in charge of P#3. The email was an after the fact explanation of events after staff reviewed the chart and stated that "view on the delay was waiting for the patient's family as he was a minor, also, waiting for results to determine if the patient should remain at our facility or be transferred."

E. Record review of P#3's chart revealed documentation that stated P#3's mother was " notified by House Supervisor upon PT (patient) arrival at 2005 (08:05 pm) where verbal consent for treatment was already received."

F. Record review of the facility Policy on Transfers dated 12/27/18 states that "Any issues regarding transfers will be referred to the director/manager of the department making the transfer in writing, thereby ensuring continuous performance improvement/customer service."

G. Record review of "History and Physical" dated 06/27/19 revealed, P#3 was a pediatric (17 years old) patient "who was involved in a motorcycle accident, was helmeted driver of a motorcycle going approximately 60 miles/hr, was cut off by a car, motorcycle struck car in a T-bone fashion and patient flew through the air and landed on asphalt, his helmet was severely cracked, has an obvious open fracture of his left lower leg, some difficulty following commands."

H. Record review of "Centers for Disease Control and Prevention Guidelines for Field Triage of Injured Patients" dated January 2012 revealed, "2 or more proximal long bone fracture necessitates immediate transfer to a trauma center, motorcycle crash greater than 20 miles/hour necessitates transfer to a trauma center."

I. On 10/16/19 at 10:00 am,during interview S#7 confirmed the facility has no Trauma Level designation (is not a trauma center). In addition, S#7 confirmed being unable to provide documentation of communication with EMS (Emergency Medical Service) concerning the above patient.

Based on record review and interview, the facility failed to ensure that sufficient staff needed to provide services essential to the operation of the CAH (Community Access Hospital) was readily available and results of exams utilized for treating emergency cases readily available to the ED (Emergency Department) physicians and can effect all patients in the facility. This failed practice has the potential to delay treatment and interventions which may result in further patient injury or harm when patients who suffer traumatic injuries cannot be transferred to centers able to provide necessary treatment. The findings are:

A. Record review of "History and Physical" dated 06/27/19 revealed, P#3 was a pediatric (17 years old) patient "who was involved in a motorcycle accident, was helmeted driver of a motorcycle going approximately 60 miles/hr, was cut off by a car, motorcycle struck car in a T-bone fashion and patient flew through the air and landed on asphalt, his helmet was severely cracked, has an obvious open fracture of his left lower leg, some difficulty following commands."

B. Record review of P#3's CT (Computed Tomography) scans dated 06/27/19 revealed:
1. CT cervical spine (area of the back encompassing the neck) "Partially imaged pneumomediastinum (damage to the lungs that allows air to leak into the center of the chest) and small medial right pneumothorax (complete lung collapse or a collapse of only a portion of the lung)
2. CT head "Right maxillary fluid level and correlate for evidence of facial or right orbital trauma (injury to the bone surrounding the eye and sinuses)
3. CT left lower extremity "Oblique comminuted displaced fractures of the distal femoral diaphysis and proximal tibial diaphysis" (skin open and breaks of the thigh and lower bones of the leg)
4. CT abdomen and pelvis "Dependent pelvic fluid" (possible free blood in the abdomen area).

C. Record review of P#3's chart revealed that CT (Computed Tomography) scan was ordered at 08:08 pm, was performed at 8:45 pm but was not dictated and authenticated until 10:05 pm by the radiologist (doctor that reads xrays and CT scans). P#3 was not transported to the Level 1 trauma center until 10:52 pm by air ambulance.

D. Record review of an email communication from S#7 dated 10/21/19 confirmed the delay in transfer to a Level 1 trauma facility for P#3 was due to CT results not reported to the ED doctor until 10:05 pm.

E. Record review of American Trauma Society undated website revealed a Level 1 trauma hospital ED provides, "24-hour in-house coverage by general surgeons, and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric and critical care". P#3 was a pediatric patient who was confused and required surgical intervention.

F. Record review of "Interfacility Transfer of Injured Patients: Guidelines for Rural Communities, American College of Surgeons Committee on Trauma" dated 2002 revealed, "Patients with certain specific injuries or combinations of injuries (particularly those involved the brain) or patients who have historical findings indicating high energy transfer may be at risk for death and are candidates for early transfer."

G. On 10/16/19 at 11:00 am S#7 confirmed P#3 was a Level 1 trauma patient who required transport to a trauma center as soon as possible and a delay could result in further complications for the patient.

Based on record review and interview the facility failed to provide services (i.e vital signs, pain assessment) in accordance with appropriate written facility policies for 6 P#s (P#s 1,3,4,7,8 and 9) of 10 patient records reviewed. The deficient practice has a potential to result in patients inappropriately treated and discharged which may result in further harm or illness exacerbation. The findings are:

A. On 10/16/19 at 2:30 pm during a phone interview with complainant, complainant stated that P#1 on 06/28/19, the day following discharge from hospital #1 ED (emergency department) was driven by friends for 12 hours from his home to Hospital #2 in another state and was immediately admitted to ICU ( Intensive Care Unit) secondary to severe pain with difficulty breathing related to 6 rib fractures.

B. On 10/16/19 at 10:30 am, during phone interview with S#2 Radiologist, confirmed that after reviewing the bone windows of the CT (Computed Tomography) scan of P#1, that there were 2 non displaced rib fractures present which he failed to read on the date of ED presentation on 06/27/2019.

C. Record review of P#1's ED Record dated 06/27/19 revealed that pain level was not re-assessed prior to discharge. P#1's record revealed that his chief complaint upon arrival to ED of Hospital #1 on 06/27/2019 was "82 years old, Back Pain, Thrown off Horse".

D. Record review of 6 out of 10 trauma patient medical records ( P#s 1,3,4,7,8 and 9) revealed facility staff failed to record and document vital signs, specifically pain.

E. Record review of facility "Triage in the Emergency Department Policy" (c) dated 12/18/17 revealed that "The primary triage documentation will include the chief complaint, HPI -brief description of pertinent history, clinical presentation and relevant date, vital signs, any treatment initiated at the time of triage or by EMS (Emergency Medical Services), allergies, height and weight." Further on subpart (i) states vital signs must be taken every two hours.

F. Record review of P#9's "ED Record" dated 08/22/19 revealed that P#9 had been a patient in the ED for 5 hours and 11 minutes and his vital signs were only checked twice, upon arrival and after 2 hours.

G. On 10/16/19 at 11:00 am during interview with S#7 DPCS ( Director of Patient Care Services), confirmed that they check vital signs every 2 hours in the ED. When asked if she would re-check vital signs before discharge, she stated "yes".

H. On 10/16/19 at 11:10 am during interview with S#3 Registered Nurse (RN), confirmed that in the ED, the policy is to check vital signs every 2 hours.

I. On 10/16/19 at 11:30 am during interview with S#4 RN, also confirmed that the facility policy is to check vital signs every 2 hours in the ED.

J. On 10/16/19 at 4:23 pm during interview with S#6 Registered Nurse (RN) House Shift Supervisor, she also confirmed that pain is considered as part of the vital signs.

Based on record review and interview, the facility failed to ensure that emergency services are provided in accordance with the requirements of §485.618 for the CAH (Critical Access Hospital). This failed practice has the potential to cause further harm or injury to patients requiring emergency care and can effect all hospital patients. The findings are:

A. Record review of P#3's chart revealed that a cervical collar (neck brace or a medical device used to support a person's neck, applied by emergency personnel to those who have had traumatic head or neck injuries) was placed upon arrival to the Emergency Department (ED) by ED staff (not by EMS/Emergency Medical Services). P#3 was not placed on a backboard prior to or after arrival in the ED (Emergency Department).

B. On 10/16/19 at 10:00 am, during interview, S#7 DPCS (Director of Patient Care Services), confirmed that there is an ongoing issue with the EMS (Emergency Medical Services) regarding placing cervical collars as required. She further stated that they get patients in their ED ( Emergency Department) without cervical collars or on backboards most of the time. She stated that current research indicates backboards and cervical collars are not always required, but did not know the requirements or have a policy stipulating which patients require immobilization.

C. Record review of an email communication with S#7 DPCS dated 10/21/2019, confirmed that the facility has taken no action in reviewing the requirements for patients sustaining traumatic injury and requiring cervical collars and backboards with EMS.

D. Record review of "The Changing Standard of Care Journal of Emergency Medicine" dated 2016 revealed "Currently recommendations call for selective spinal immobilization to decrease unnecessary application and potential harm. Use of backboards for spinal immobilization should be limited to the following types of patients, High energy mechanism of injury."

E. Record review of "History and Physical" dated 06/27/19 revealed, P#3 was a 17 year old patient "who was involved in a motorcycle accident, was helmeted driver of a motorcycle going approximately 60 miles/hr, was cut off by a car, motorcycle struck car in a T-bone fashion and patient flew through the air and landed on asphalt, his helmet was severely cracked, has an obvious open fracture of his left lower leg, some difficulty following commands."