HospitalInspections.org

Based on review of patient records, hospital policies and procedures, and staff interviews, the hospital failed to comply with all requirements of 489.24. The survey report was reviewed and revised by Kate Mitchell, RN with the Centers for Medicare & Medicaid Services.

Refer to citations and examples at

Tag A2405 Emergency Department Log-the hospital failed to ensure that all entries were completed for each patient seen in the ED.

Based on record review, review of policy and procedure, and staff interview, the hospital failed to ensure the Emergency Department Log included all required information on each patient who had received care at the hospital.

Findings:

Review of the Emergency Log for November, 2009 through May, 2010 revealed that staff failed to enter information for patients who had been registered and seen for care. Missing information included diagnosis, disposition, discharge date and time and occurred multiple times over the period reviewed (for example, see 2/16, 4/24, and 5/3, 7, 10/ 2010). Staff interview on 5/12/2010 verified that the information was not being regularly entered in the log.
Review of the hospital policy "EMTALA- Emergency Medical Treatment and Active Labor Act" (Index #2.0017) directed under "Emergency/OB Log, "The log must indicate...the disposition which could include:...the patient was ... transferred; admitted and treated; stabilized and transferred; treated and discharged."
Interview with administrative nursing staff on 5/12/2010 revealed that discharge information was available on another tracking tool, but not on the Emergency Department Log.