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Based on interview and record review the facility failed to keep family members informed of patient's condition and did not have a policy and procedure to notify family members of a trauma patient's condition after admission for one (1) of thirty-two (32) sampled patients (Patient 1). Patient 1 was admitted, 5/23/2023 at 8:54 a.m., as a trauma patient (a person who has suffered a physical injury which may be serious or potentially life-threatening) and family members were not informed of Patient 1's condition after admission.

The deficient practice resulted to Patient 1's family not being informed about Patient 1's course of treatment and condition. Patient 1's family was informed of Patient 1's condition when Patient 1 had expired, 5/23/2023 at 9:45 a.m. (51 minutes after being admitted in the emergency room).

Findings:

A review of Patient 1's Admission/Registration record, on 5/23/2023, indicated Patient 1 was admitted at 8:54 a.m. and discharged at 9:45 a.m. The record indicated two family members listed (Family Member 1 [FM 1] and FM 2) on the emergency contact list.

A review of Patient 1's Trauma History and Physical, dated 5/23/2023, indicated Patient 1 had a fall 20 feet. Patient 1 was, "Combative but not talking or opening eyes." Patient 1 initial had a pulse (heartbeat) and this it (pulse) was lost with pulseless electrical activity (PEA, a condition where the heart stops because the electrical activity is the heart is too weak to make the heartbeat).

A review of Patient 1's Emergency Department Provider Note, date 5/23/23, indicated Emergency Medical Service (EMS, a system that provides emergency medical care) reports Patient 1's lips became cyanotic (blue) just prior to emergency department (ED) arrival. The record indicated Patient 1 was a tier 1 trauma (patients with the most serious injuries) in severe distress, very agitated, and cyanotic. Patient 1 required emergency intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea (airway/windpipe) to assist with breathing). Patient 1 arrived at 8:54 a.m. and code (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert) at 9:01 a.m. The record indicated the code ended at 9:34 a.m. and Patient 1 was discharge at 9:45 a.m.

A record review of Patient 1's Social Work (SW) note, dated 5/23/2023 at 9:45 a.m., indicated social worker had received a consult from the Trauma team that Patient 1's family was outside the emergency room and to escort the family to the family room (room inside the emergency room where personal discussions can be held). The record indicated the Trauma team had informed SW that Patient 1 had expired. The record indicated, "SW introduced self and role as hospital social worker. SW provided emphatic statements." The record indicated family member that included FM 1 were hostile, and family yelled that they (family) did not want to speak to the Social Worker. SW was not available for interview.

A review of Patient 1's Record of Patient Death, dated 5/23/2023, indicated notification were provided by Medical Doctor 4 (MD 4, Emergency Doctor) to FM 1 and FM 2 at 11:30 a.m.

During an interview, on 7/19/2023 at 9:50 a.m., MD 4 stated that he went to see the family after Patient 1 had passed. MD 4 stated he spoke with the family. MD 4 stated during an emergency situation, it was not a priority for nursing to update family of a patient's condition.

A review of Patient 1's medical records, indicated there were no documentation that Patient 1's family members had been notified of Patient 1's condition prior to his death.

During an interview, on 7/19/2023 at 4:30 p.m., the Director of Quality (DQ) confirmed that the facility did not have any policy and procedure guidance regarding notification of a trauma patient's family members when the patient's condition has changed after admission.