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Based on interview, observation, policy and procedure review, and documentation in 5 of 5 records reviewed of patients who left the Emergency Department (ED) of the hospital's satellite location without being seen by a physician (#'s 2, 3, 4, 6 and 13) it was determined that the hospital failed to ensure that the records were accurately written, promptly completed, and reflected the patient's course and progress through the ED. Findings include:

1. The record of patient #2 revealed an ED "Checkin" date of 9/14/10 at 1305. The "Visit Reason" was identified as "Shoulder pain-swelling*; LWBS". The patient was evaluated and vital signs were obtained by the Triage RN. The patient was identified by the RN as having sharp left shoulder pain. The disposition of the patient was documented as "Left Without Being Seen" and the "Checkout" was noted as 9/14/10 at 1451. There was no documentation to describe the circumstances surrounding the patient leaving the ED.

2. The record of patient #3 revealed an ED "Checkin" date of 10/4/10 at 1931. The "Visit Reason" was identified as "Lethargy; Neck pain; Nausea*; HA-Headache; MVA". Documentation reflects that the patient was seen and triaged by an RN beginning at 1951. The disposition of the patient was documented as "Left Without Being Seen" and the "Checkout" time was noted as 10/4/10 at 2136. A form titled "Triage/Medical Screening AMA [Against Medical Advice] Consent" was noted in the record. An "X" had been written in a box on the form next to "Decline Medical Screening Examination". The form was signed by the patient and a "Witness (Emergency Department Staff)". The form was dated 10/4/10 and the time was noted as 2136. Another form titled "Consent for Treatment/Conditions of Admission" was signed by the patient. It was dated 10/4/10 and the time was noted as 2148, 12 minutes after the documented "Checkout" time. There was no other documentation in the record related to the patient's encounter in the ED. The record did not describe the circumstances which led to the patient leaving without a medical screening examination, or the patient's condition at that time.

3. The record of patient #4 revealed an ED "Checkin" date of 10/11/10 at 1645. The "Reason For Visit" was identified as "unknown". The "Checkout" was noted as 10/11/10 at 1700. Documentation in a narrative "Late entry note" dated 10/22/10 at 1447 indicated that the patient was brought to the triage area of the ED. The note further reflected that the triage was not completed and the patient left the ED. The disposition of the patient was documented as "Left Without Being Seen".

During an interview conducted 12/9/10 at 1345 with the Director of Emergency Services and the Integrated Patient Support Director, it was confirmed that the Triage RN failed to initiate an ED record and document the ED encounter with patient #4 until 10/22/10, 11 days after the 10/11/10 ED visit.

Additionally, observations of hospital security video footage of the ED entry, waiting, and reception area was viewed on 12/9/10 at 1500. The video recording reflected that patient #4 entered the ED and checked in at reception on 10/11/10 at 1650, entered the triage area at 1653, and exited the triage area and the ED at 1654. The documentation in the patient's record did not accurately reflect the patient's actual time in the ED.

4. The record of patient #6 revealed an ED "Checkin" date of 10/16/10 at 1914. The "Visit Reason" was identified as "Nausea". The "Checkout" was noted as 10/16/10 at 1956. The disposition of the patient was documented as "Left Without Being Seen". There was no documentation to describe the circumstances surrounding the patient leaving the ED.

5. The record of 14 year-old patient #13 revealed an ED "Checkin" date of 11/15/10 at 2140. The "Visit Reason" was identified as "ankle pain". The disposition of the patient was documented as "Left Without Being Seen" and "Checkout" was noted as 11/15/10 at 2155. There was no other documentation in the record related to the patient's encounter in the ED. The record did not describe whether this minor child presented with another person, the mode of arrival, which staff he/she checked in with, and what the circumstances were surrounding his/her leaving the ED without being seen.

6. Review of the hospital policy titled "Patient Leaving Facility Against Medical Advice (AMA)", identified as "Reviewed: April 2010", required "Document the chain of events... in the patient's chart".

7. During an interview conducted 12/9/10 at 1730 the Director of Emergency Services verbalized that the medical records for patients that leave the ED without being seen should include, at a minimum, a documented description of the circumstances surrounding the patient leaving.




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