HospitalInspections.org

Based on observation and staff interview it was determined the facility failed to complete electrical testing in the radiology department, resulting in an unsafe condition (refer to Tag K 921). Census is 10.

Based on document review and staff interview it was determined the facility failed to ensure the Emergency Department (ED) staff followed facility policy and accurately completed the ED Central Log Book for three (3) of three (3) months reviewed (April 2017, May 2017 and June 2017). This deficient practice has the potential to negatively affect the prompt care and disposition of all patients.

Findings include:

1. Review of the ED Central Log Book from 4/1/17 through 6/19/17 revealed incomplete documentation as follows: April 2017 had four (4) days of incomplete documentation; May 2017 had eight (8) days of incomplete documentation; and, June 2017 had eight (8) days of incomplete documentation.

2. Review of the facility policy titled "Registering of Patients in the ER Log", last reviewed 4/10, revealed it states, in part: "...any patient presenting for emergency care, or a woman in labor, as designated by EMTALA are to be registered on a Central Log, herein identified as the Emergency room log. The purpose of this log is to track the care provided to each individual presenting for care and treatment...The Admissions Department will forward a copy of the ER patient's face sheet to the ER. The ER clerical staff is to record this data in the log on Optimun. Under the treatment section of the log book the clerk will note all treatment given while in the ER."

3. Review of the Emergency Room (ER) staff meeting minutes for February 2017 revealed it states, in part: "All patients triaged from front will be logged by the Mid-Level. All patients triaged from ambulance entrance will be logged by the RN who is triaging the patient. The nurse/mid-level discharging/admitting/transferring etc, is responsible for filling in the disposition, disposition diagnosis, date and time on the log book. It is to be filled out immediately on disposition. If you fail to do your job disciplinary actions will be enforced. Do not write the complaint in the log book. Write the disposition diagnosis. The Unit Clerks will be the second eye and recheck the log book to make sure all patients were logged and the disposition is completed. No one is to leave from their scheduled shift without making sure the log is up to date..."

4. The above findings were reviewed on 6/21/17 at 11:14 a.m. with the ER Nurse Manager. She confirmed the findings.