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Based on review of documentation in the medical record of patients (Patient 3) reviewed for medical record requests, it was determined the hospital failed to supply the patient with all requested medical record documents.

Findings include:

The medical record for Patient 3 reflected he/she was brought to the ED on 05/14/2018 by EMS ambulance and was subsequently transferred to another hospital for further treatment. The ED record included a medical record request form titled "Patient Request to Access/Disclose a Designated Recod Set - Hospital" signed by the patient and dated on 07/06/2018 that reflected a request for "Diagnostic Report (lab, x-ray, EKG, etc.) ... Other (specify): Ambulance Report ... Discharge Summary ... Emergency Department Report ... for date of service 05/14/2018." A document titled "History for Release of Information ..." reflected the patient's request for medical records was fulfilled and completed on "07/06/2018 1211." The printed list of the documents the patient was given reflects he/she recieved lab results, CT scan, XR studies, ED Provider Notes and EMS documentation of the patient's transfer from PSVMC to OHSU. The medical record did not have the Ambulance report for the arrival to PSVMC.

Based on interview and review of documentation in 2 of 7 medical records (Patient 1 and 3) and review of policies and procedures it was determined that the hospital failed to implement its policies and procedures for obtaining vital signs, assessing pain levels and providing patients with injuries alternative methods of communication.

Findings include:

1. a. Review of the policy and procedure titled "Regional Nursing Minimum Documentation Reference" dated as last reviewed "01/2017" contained the following references to ED patients:

* "Vital Signs are taken upon arrival: Temperature, Pulse, Respirations, Blood Pressure, Oxygen saturation and pain level.
-This will be based on chief complaint and any change in condition.
-Abnormal vital signs on arrival should be reassessed within one hour or sooner if intervention provided.
-Vital signs every 4 hours and more frequently as patient condition dictates.
* Pain Assessment: On arrival and post intervention.
-Pain assessment with pain rating, description and assessment tool.
-If no pain on admission, evaluate upon assumption of care and as condition warrants.
-Pain rating.
-If there is a change in pain and/or change in pain location, include: Reassessment is completed according to the patient condition."

b. Review of the policy and procedure titled "ED Practice Guideline: Adult Initial Assessment and Reassessments" dated as last reviewed "04/2017" contained the following references:

* "Complete an initial assessment in the Emergency Department, which may include, based on the patient presentation and nursing judgment:
-Environmental/safety factors.
-Self-care capabilities.
* Obtain and document vital signs (to include temperature, blood pressure, heart rate, respiratory rate and pulse oximetry).
* Assess and document pain using an appropriate pain rating scale.
* Consider the patients age, chief complaint, concurrent medical conditions and special needs, when determining monitoring and assessment requirements.
* Reassess/monitor for outcomes."

2. Review of the medical record for Patient 3 reflected that he/she was admitted to the ED on 05/14/2018 at 0957 via EMS with chief complaint of: bicycle crash, facial injury, and bilateral wrist pain. The record reflected the following:
* At 1024 the patient was placed in an ED treatment room.
* At 1032 BP 106/67
* At 1102 BP 116/59
* A complete set of vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation) were not taken until 1114 and were recorded as Temp 36.6 C, Pulse 80, Resp 18, SpO2 97%.
* The patients temperature was not recorded again for over eight hours at 1944.
* The patient transferred to OHSU 14 minutes later at 1959.

During the course of the ED visit the patient was evaluated to have multiple fractures including: right TMJ fracture; left mandibular fracture; left radial neck fracture; left boxer's fracture; right third, fourth, fifth proximal metacarpal fractures; and right lunate fracture. The patient was fitted with a ulnar gutter splint with a sling on the left arm and the RUE was placed in a volar splint. The chart reflected that he/she could not sign the consent for ED treatment or the EMTALA transfer form due to his/her injuries. There was no documentation to reflect a call light was in reach, that frequent visual checks were performed and there were no safety notes in the patient's record. The nursing staff did not provide an alternative way for the patient to call for help. Nor was there documentation to reflect that an alternative method of nurse call was provided.

3. Review of the medical record for Patient 1 reflected that he/she arrived to the ED on 05/07/2018 at 0912 with chief complaint of: bicycle crash, hand injury, leg injury and rib pain. There was no documentation to reflect that vital signs were taken or a pain assessment conducted until 1326, over 4 hours after arrival to the ED. There was no other vital signs or pain assessment documentation while the patient was in the ED. The patient was transferred to an inpatient unit at 1400.

4. During the interview with the DON and EDM on 09/07/2018 at the time of the medical record review, they confirmed that there were no other vital signs, nurse call, or pain assessment documentation in the records of Patients 1 and 3.