HospitalInspections.org

Based on staff interviews and policy review the CAH failed to ensure staff responsible for the management and coordination during a EMS (Emergency Management System) Diversion followed the Critical Access Hospital (CAH) policy and procedure process. Findings include:

The CAH policy Facility Alert - EMS Diversion is enacted upon after the recommendation from CAH administration that transporting EMS agencies divert patients to an alternative appropriate hospital facility. Diversion can result due to a medical surge capacity or critical patient surge. The CAH utilized Diversion during times in June and July/2024 when the CT scanner (Computed tomography) "went down". Due to the necessity of this diagnostic imagery being utilized to determine disease or injury, the Emergency Department physicians in collaboration with the CAH house supervisor would enact a Diversion status when the CT scanner was not in service. As a result, certain patients would be transported to another hospital with a functioning CT scanner.

Per facility policy, "the supervisor will complete the CAH EMS Diversion log entry to document Diversion event". This activation also includes: contacting ED Medical Director, all local EMS, hospitals and mental health organizations within the CAH region of service. Per interview on 7/23/24 at 11:16 AM the QA/PI manager confirmed although Diversions had been enacted, there are no Diversion log entries, as required per policy. It was further confirmed the CAH nursing supervisor was the responsible individual to complete the log. As a result, there was a lack of tracking of these Diversion events, preventing appropriate review of the process and tracking of actual times when a Diversion was being utilized. Diversion is generally isolated occurrences which require tracking and review. The CAH was unable to provide any of the required documentation as per Diversion policy.