HospitalInspections.org

Based on record review and interview, the hospital failed to ensure compliance with the
requirements of CFR 489.24 as evidenced by:

1 Failing to have a central log since 8/1/15 on each individual who came to the emergency
department seeking assistance and whether he or she refused treatment, was refused
treatment, or whether he or she was transferred, admitted and treated, stabilized and
transferred, or discharged; (See findings at C-2405).

2) Failing to provide documented evidence to ensure that a medical screening examination
was performed by a qualified practitioner for 18 (#1, #4, #5, #6, #7, #8, #9, #10, #11,
#12, #13, #14, #15, #16, #17, #18, #19, #20) of 20 (#1 - #20) patients who presented to
the hospital's Emergency Department seeking treatment. (See findings at C-2406).

Based on record review and interview, the hospital failed to have a central log since 8/1/15 on each individual who came to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged.

Findings:

The emergency department log from 8/1/15 through present date was requested for review from S9AsstAdmin on 12/8/15 at 10:00 a.m. No log was presented by the hospital.

In an interview on 12/8/15 at 1:37 p.m. with S9AsstAdmin, she verified there was no emergency department log since the new computer system was put into place at the beginning of August 2015. She said she could retrieve some of the data that was needed in a log from a billing section of the electronic record, but the true log information would have to be manually entered into the system and it had not been. She verified the report generated for billing did not include information required by the state of Louisiana for sex, mode of arrival, nature of complaint, and disposition of the patient.

In an interview on 12/8/15 at 2:22 p.m. with S3ADON, she said she was unaware the emergency department did not have a log since August 2015.

In an interview on 12/08/15 at 3:30 p.m. with S1CEO, he said he was not aware the emergency department did not have a log of patients since August 2015.

Based on record review and interview, the hospital failed to provide documented evidence to ensure that a medical screening examination was performed by a qualified practitioner for 18 (#1, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) of 20 (#1 - #20) patients who presented to the hospital's Emergency Department seeking treatment.

Findings:

Patient #1
Review of Patient #1's medical record revealed she presented to the hospital's emergency department on 9/5/15 at 1:00 p.m. and was discharged on 9/5/15 at 4:46 p.m. Review of the nursing triage note revealed Patient #1's chief complaint was rectal bleeding. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #4
Review of Patient #4's medical record revealed she presented to the hospital's emergency department on 9/9/15 at 8:42 p.m. and was discharged on 9/9/15 at 10:25 p.m. Review of the nursing triage note revealed Patient #4's chief complaint was a headache for 2 days. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #5
Review of Patient #5's medical record revealed she presented to the hospital's emergency department on 8/13/15 at 6:46 p.m. and was discharged on 8/13/15 at 10:10 p.m. Review of the nursing triage note revealed Patient #5's chief complaint was pain over the entire body for 2 days. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #6
Review of Patient #6's medical record revealed he presented to the hospital's emergency department on 9/23/15 at 5:22 p.m. and was discharged on 9/23/15 at 7:33 p.m. Review of the nursing triage note revealed Patient #6's chief complaint was pain to the right 5th digit and right wrist pain. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #7
Review of Patient #7's medical record revealed he presented to the hospital's emergency department on 8/13/15 at 10:01 p.m. and was discharged on 8/14/15 at 1:40 a.m. Review of the nursing triage note revealed Patient #7's chief complaint was a laceration to the inside of the mouth. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #8
Review of Patient #8's medical record revealed she presented to the hospital's emergency department on 9/10/15 at 2:45 a.m. and was discharged on 9/10/15 at 4:14 a.m. Review of the nursing triage note revealed Patient #8's chief complaint was constipation. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #9
Review of Patient #9's medical record revealed she presented to the hospital's emergency department on 11/8/15 at 1:44 p.m. and was discharged on 11/8/15 at 3:07 p.m. Review of the nursing triage note revealed Patient #9's chief complaint was a laceration to the forehead. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #10
Review of Patient #10's medical record revealed she presented to the hospital's emergency department on 8/13/15 at 7:10 p.m. and was discharged on 8/13/15 at 10:50 p.m. Review of the nursing triage note revealed Patient #10's chief complaint was coughing and an accumulation of phlegm in her throat. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #11
Review of Patient #11's medical record revealed she presented to the hospital's emergency department on 10/10/15 at 8:41 a.m. and was discharged on 10/10/15 at 10:12 a.m. Review of the nursing triage note revealed Patient #11's chief complaint was a prescription refill. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #12
Review of Patient #12's medical record revealed he presented to the hospital's emergency department on 8/28/15 at 9:41 p.m. and was discharged on 8/29/15 at 2:05 a.m. Review of the nursing triage note revealed Patient #12's chief complaint was a child with an allergic reaction. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #13
Review of Patient #13's medical record revealed she presented to the hospital's emergency department on 8/29/15 at 1:53 p.m. and was discharged on 8/29/15 at 6:24 p.m. Review of the nursing triage note revealed Patient #13's chief complaint was chest pain. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #14
Review of Patient #14's medical record revealed he presented to the hospital's emergency department on 11/3/15 at 6:59 p.m. and was discharged on 11/3/15 at 8:31 p.m. Review of the nursing triage note revealed Patient #14's chief complaint was lower back pain. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #15
Review of Patient #15's medical record revealed he presented to the hospital's emergency department on 11/7/15 at 4:34 p.m. and was discharged on 11/7/15 at 4:45 p.m. Review of the nursing triage note revealed Patient #15's chief complaint was an elevated blood pressure. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #16
Review of Patient #16's medical record revealed she presented to the hospital's emergency department on 10/21/15 at 5:45 a.m. and was discharged on 10/21/15 at 7:12 a.m. Review of the nursing triage note revealed Patient #16's chief complaint was shortness of breath. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #17
Review of Patient #17's medical record revealed she presented to the hospital's emergency department on 10/20/15 at 8:54 p.m. and was discharged on 10/20/15 at 11:20 p.m. Review of the nursing triage note revealed Patient #17's chief complaint was a fever. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #18
Review of Patient #18's medical record revealed he presented to the hospital's emergency department on 9/20/15 at 8:55 p.m. and was discharged on 9/20/15 at 9:29 p.m. Review of the nursing triage note revealed Patient #18's chief complaint was increased pain and discomfort. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #19
Review of Patient #19's medical record revealed she presented to the hospital's emergency department on 9/28/15 at 10:36 p.m. and was discharged on 9/29/15 at 12:16 a.m. Review of the nursing triage note revealed Patient #19's chief complaint was increased blood pressure. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

Patient #20
Review of Patient #20's medical record revealed she presented to the hospital's emergency department on 9/28/15 at 10:30 p.m. and was discharged on 9/29/15 at 1:48 a.m. Review of the nursing triage note revealed Patient #20's chief complaint was leg pain. There was no documentation in the medical record to indicate that a medical screening examination was performed by a qualified practitioner.

In an interview on 12/7/15 at 12:07 p.m. with S4RHIT, she said a list of emergency department patients' medical records that were delinquent had been provided by Staffing Agency "A". She said she had offered assistance to the physicians with completing the medical records and assistance using the computer documentation system but S5Physician had refused her help because he did not like the electronic medical record. She said all of the physicians were offered training on the new computer charting system, but S5Physician and S6Physician were not willing to participate in the training. S4RHIT said it was not acceptable for the physicians not to have documentation of screenings and exams in the patients' medical records. She verified the medical records for Patients #1 and #4 - #20 did not have a medical screening examination documented.

In an interview on 12/7/15 at 12:43 p.m. with S2DON, she said the hospital had noticed a problem with emergency department physicians not completing their documentation in the patients' medical records. S2DON verified there was no way to determine if a medical screening was completed by the physicians on Patients #1 and #4 - #20 because there was no documentation by the physicians in the patients' medical records. S2DON agreed no documentation by the physicians in multiple emergency room records was unacceptable practice.

In an interview on 12/7/15 at 1:37 p.m. with S1CEO, he said he realized some of the physicians were not documenting a medical screening exam in the emergency department records. S1CEO said there were many emergency department records missing all or part of the physician components. S1CEO verified if there was no documentation in the medical record of a physician assessment or screening it could not be determined if an exam had been completed. S1CEO also said no alternative to the computer documentation system being used in the emergency department had been implemented to ensure compliance with completion of the medical records by the physicians. S1CEO also agreed no action had been taken to ensure the completion of medical records by the ED physicians.

In an interview on 12/7/15 on 2:17 p.m. with S5Physician, he said he was the ED director. He said there was no screening on some of the patients because they transitioned to a new medical record computer system. S5Physician said he would not say he did a note on every patient, but some of the notes must have disappeared. S5Physician said he had screened all of his patients but the documentation was not in many of their records. S5Physician said the documentation system was the problem. S5Physician said if he did not hit the save button on the computer his information would disappear. When asked if he had alternative documentation of patients' screenings and assessments, S5Physician said, "No".