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Based on medical record review, staff interview, and facility policy review, the facility failed to ensure staff followed the current facility policy related to a thirty minute response time of department/section to the Emergency Department for consultation. This affected one patient (Patient #2) of eleven medical records reviewed. The Emergency Department census was 95.

Findings include:

Review of the medical record of Patient #2 revealed the patient arrived to the Emergency Department on 09/23/22 at 7:48 PM after the patient fell on his face in a parking lot. A laceration and hematoma to the patient's right eyebrow was visible by staff. The note further revealed the patient was bleeding from the nose although the bleeding was described as "controlled." An order was placed to consult trauma surgery at 9:05 PM. A note three minutes later, at 9:08 PM, stated the trauma team was aware of the order for consult for the patient and would come to the patient's room for an evaluation. At 9:10 PM an order for the consult of trauma surgery was acknowledged. The patient was given a tetanus shot in the right deltoid at 9:36 PM. A note composed by a emergency department physician assistant at 9:37 PM described the laceration repair on the patient's forehead. The patient was medicated with 3 ml of lidocaine 1% followed by placement of four sutures. A Trauma Service H&P Note composed by Staff I at 10:37 PM was reviewed. The impression/plan stated the following: As the trauma team leader, I spoke with the attending trauma surgeon at 10:30 PM. "This was within 30 minutes of the patient's arrival. The attending trauma surgeon participated in the decision-making regarding interventions and imaging. They were made aware of all positive imaging results and agreed with my plan as described during this communication." The H&P was signed and attested by the trauma surgeon. The attestation stated: "I spoke to the trauma surgery physician's assistant shortly after his evaluation of the patient on the evening of 9/23/22. Patient is status post fall. The patient was walking outside when reportedly his car was stolen. He was struck in the face. He does have a closed nasal bone fracture as well as a history of syncope with questionable concussive type symptoms. Patient will be admitted to the trauma service. Internal medicine in consulted. We will follow-up on imaging results."

Staff A was interviewed on 11/23/22 at 12:00 PM and asked if there was a time limit for consult teams to evaluate patients once requested. Staff A explained that a phone log is kept at the front desk in the ED. The log tracks the time the team being consulted is informed and from that time, the team must evaluate the patient within 30 minutes.

Review of the Emergency Department Phone Log from 9/23/22 revealed the trauma team was consulted at 9:08 PM. Review of the patient care timeline of Patient #2 revealed that the patient wasn't evaluated until 10:37 PM, one hour and 29 minutes after being consulted.

Staff F and Staff I were interviewed on 11/23/22 at 5:30 PM. Staff F explained that the impression/plan statement is merely an auto-populated statement with a drop down box where the name of the trauma surgeon is selected and a space for the time is left for the physician assistant to put the time. Staff I stated that he believed that the consult actually occurred within the required 30 minutes and stated that a better way of determining exactly when the evaluation occurred would be to review the timing of any orders written after the evaluation. The orders were reviewed. An order by Staff I for staff to apply ice to affected area of right eye was noted on 9/23/22 at 10:50 PM.

It was confirmed with Staff F and Staff I that this order occurred after the documented evaluation at 10:37 PM, both over the thirty minute requirement.

Review of the medical staff policy titled "Response Time", approved by the Medical Executive Committee on 11/10/21, stated that departments and sections are encouraged to determine a response time. The Medical Executive Committee will review and approve the insertion of this response time into the rules and regulations of the department or section. Unless a different requirement is set forth in the Rules and Regulations of a department or section, each member of the Medical Staff, or his/her covering practitioner, shall be expected to arrive at the hospital within 30 minutes, any time of day or night, if notified of the need requiring the practitioners presence.