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Based on record review, review of the Plan of Correction, review of policies and procedures, and interviews with key staff members and patient family members on July 15 - 16, 2010, it was determined that the governing body failed to ensure that policies are administered so as to provide quality health care.

Findings include:

Patient A

1. Down East Community Hospital failed to follow the ' Nursing Immediate Care Protocol ' for ' Suspected Head/Spine Injury, Major Trauma ' (for further information see Tag C-0274), and failed to identify the care issue in the review process (for further information see Tag C-0336).

Patient B

2. Down East Community Hospital failed to follow the ' TIA Workup/Disposition Planning Protocol ' (for further information see Tag C-0274).

Patient C

3. Down East Community Hospital failed to follow the standards outlined in the ' Emergency Medicine, A Comprehensive Study Guide, 6th ed. ' (for further information see Tag C-0274), and failed to identify the care issue in the review process (for further information see Tag C-0336).

Based on record review, review of the Plan of Correction, review of policies and procedures, and interviews with key staff members and patient family members on July 15 - 16, 2010, it was determined that the critical access hospital failed to follow emergency services policies and procedures.

Findings include:

Patient A

1. Down East Community Hospital ' s Plan of Correction dated March 23, 2009 included a ' Nursing Immediate Care Protocol ' for ' Suspected Head/Spine Injury, Major Trauma ' which stated " Ensure immobilization of entire spine on long board, apply c-collar and head immobilizing device. "

2. The ' Emergency Department Triage Note ' for Patient A stated " says [he/she] was swimming and dived into water striking [his/her] head on a rock. Says neck is stiff, lac on left parietal area, no active bleeding. " The ' Patient Progress Notes ' for Patient A stated " pt [patient] ambulatory to ER5 from triage. Pt is alert and oriented. C spine precautions in place. " Additionally, no further neurological examinations are documented following the initial examination.

3. The potential Impact from this failure to recognize a potentially unstable neck injury and to immediately stabilize and completely immobilize the cervical spine includes significant, permanent neurological injury, quadriplegia or death. These complications may be caused by permitting the patient to walk to the exam room, and are preventable with appropriate immobilization and stabilization.

Patient B

4. According to Emergency Department Records, Patient B received care in the Emergency Department twice within two days. The ' Emergency Room Note ' from the second visit listed " slurred speech, unclear etiology " and " possible transient ischemic attack " under " Final Impression. "

5. The ' TIA Workup/Disposition Planning Protocol ' listed ' Indications for High Risk for Recurrence. ' This flowsheet continued that if none of these indications was present the patient should have an outpatient carotid ultrasound and echocardiogram. The flowsheet continued that if these tests were not available within 24 hours, the patient should be transferred.

6. The ' Emergency Room Note ' for Patient B ' s second visit stated that although Patient B was offered admission, Patient B decided to return to his/her home state and follow-up with his/her physician there. This Note continued " They think that they can arrange for 48 hour MRI, which is recommended as well as carotid Dopplers as well as cardiac echocardiogram within the 48 hours of returning. " Although the Clinical Director of Nursing Services stated during an interview on July 15, 2010 that Patient B was heading to his/her home state the next day and that Patient B ' s emergency record had been faxed to Patient B ' s physician, there was no documentation of contact with Patient B ' s physician or of testing being scheduled in Patient B ' s medical record.

7. The potential impact of the failure to ensure testing for a patient with a Transient ischemic attack is the possible onset of stroke from a preventable cause, causing the patient to be left with permanent neurological deficits, significant disability or death..

Patient C

8. The ' Emergency Physician Record ' for Patient C documented the ' Clinical Impression ' as " Transient Ischemic Attack. " This Record further documented that Patient C had right-sided weakness, impaired speech, and difficulty walking and standing which had resolved.

9. Down East Community Hospital ' s Plan of Correction dated March 23, 2009 included " Emergency Department physicians are required to follow all standards outlined in the ' Emergency Medicine, A Comprehensive Study Guide, 6th ed. "

10. Emergency Medicine, A Comprehensive Study Guide, Sixth Edition (2004) American College of Emergency Physicians (McGraw-Hill Medical Publishing Division), Section nineteen, " Stroke, Transient Ischemic Attack, and Other Central Focal Conditions " page 1383 stated, " For subtle signs of lower extremity weakness, observe the patient ' s gait or have the patients walk on their toes and then on their heels. "

11. While both the ' Emergency Physician Record ' and the ' Patient Progress Notes ' for Patient C document a normal neurological exam, during interviews on July 15 & 16, 2010, Patient C ' s family members (who had been present at the Emergency Department), two Nurses and the Emergency Physician all stated that Patient C ' s ability to walk was not assessed before he/she was discharged from the Emergency Department.

12. Emergency Medicine, A Comprehensive Study Guide, Sixth Edition (2004) American College of Emergency Physicians (McGraw-Hill Medical Publishing Division), Section nineteen, " Stroke, Transient Ischemic Attack, and Other Central Focal Conditions " page 1383 stated, " Patients should be thoroughly questioned regarding recent history of TIAs. "

13. Although Patient C ' s medical record documents a single episode of symptoms, during interview on July 16, 2010, Patient C ' s family members (who had been present at the Emergency Department) stated that he/she had suffered an earlier episode of symptoms over the last twenty-four hours.

14. The ' TIA Workup/Disposition Planning Protocol ' listed ' Indications for High Risk for Recurrence. ' One of these indications is " TIA ' s of increasing frequency (crescendo TIA ' s). " This flowsheet continued that if any of these indications was present the patient should be transferred.

15. According to the ' Patient Progress Notes, ' Patient C was discharged from the Emergency Department at 6:50 PM.

16. The ' Emergency Report ' from a second hospital stated that Patient C had arrived there at 11:00 PM " still complaining of some stroke-like symptoms. " This Report continued that Patient C was admitted to the second hospital ' s intensive care unit.

Based on record review, review of the Plan of Correction, review of policies and procedures, and interviews with key staff members and patient family members on July 15 - 16, 2010, it was determined that the critical access hospital failed to effectively evaluate the quality and appropriateness of the diagnosis and treatment furnished.

Findings include:

1. Down East Community Hospital failed to obtain a complete history and physical assessment of Patient C (see Tag C-0274 for further information).

2. Down East Community Hospital ' s Plan of Correction dated March 23, 2009 included a review process to " ensure appropriate standard of care has been provided. "

3. Patient C ' s Medical Record had been reviewed and was marked " no further action needed. "