HospitalInspections.org

Based on review of the Emergency Department (ED) log, review of facility policy and staff interview the facility failed to follow facility policy for 1 (Patient (P)19) of 20 sampled patient records who presented to the facility seeking assistance were recorded on their central log. This failed practice has the potential to affect all patients presenting to the facility seeking assistance. According to facility provided information on average 1,216 patients are treated in the ED per month.

See citation A2405 and A2406 that resulted in A2400 to not be met.

Based on review of the ED log, review of facility policy and staff interview the facility failed to ensure that 1 (P19) of 20 sampled patient records who presented to the facility seeking assistance were recorded on their central log. This failed practice has the potential to affect all patients treated by the facility. According to facility provided information on average 1,216 patients are treated in the ED per month.

Findings include:

A. Review of facility policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) (Emergency Medical Treatment and Labor Act) - (Midlands)", approved 3/2023 revealed the Hospital's EMTALA obligations are activated when, an individual (or someone on that individual's behalf) requests and examination or treatment of a medical condition within a dedicated emergency department (DED).

The Central Logs must contain, at a minimum, the name of the individual seeking assistance, whether the individual refused treatment, was refused treatment, was transferred, admitted, and treated, stabilized, and transferred, discharged, or expired.

B. Review of the ED log during sample selection on 10/31/24 revealed that P19 was not listed on the ED log on 9/15/24 when P19 presented to the ED for chest pain.

C. During an interview on 11/4/24 at 1:32PM, Patient Registration Manager (PRM) revealed, that she had been made aware of situation on 9/24/24. She spoke with P19 the same day who stated that [gender] presented to the ED on 9/15/24 between 12:00PM-2:00PM. P19 stated that they "spoke to the lady at window" and "she suggested I go somewhere else."

The PRM then revealed that she had spoken with Patient Registrar -A (PR-A) who stated "I wouldn't tell anyone that" [meaning to go somewhere else]. The PRM then reviewed EMTALA with PR-A who voiced understanding.

The PRM had security verify that P19 did present to the ED on 9/15/24 after phone call with P19. Security was able to verify that P19 had presented to the ED on 9/15/24.

The contracted service then did their own investigation. The contracted service had on-site educators providing training to their staff 10/23 - 10/25/24.

D. During an interview on 11/4/24 at 2:00PM, with Chief Medical Officer (CMO) revealed, P19 was in ED on 9/23/24 and informed the MD that they were instructed to go elsewhere on 9/15/24. The MD then notified CMO of concern. The contracted service for registration staff was also notified.

Based on review of the ED log, review of facility policy and staff interview the facility failed to ensure that 1 (P19) of 20 sampled patient records who presented to the facility seeking assistance was not provided a medical screening exam (MSE). This failed practice has the potential to affect all patients that are treated in the ED. According to facility provided information on average 1,216 patients are treated in the ED per month.

Findings include:

A. Review of the ED log during sample selection on 10/31/24 revealed that P19 was not listed on the ED log on 9/15/24 when P19 presented to the ED for chest pain.

B. Review of facility policy "Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) (Emergency Medical Treatment and Labor Act) - (Midlands)", approved 3/2023 revealed the Hospital's EMTALA obligations are activated when, an individual (or someone on that individual's behalf) requests an examination or treatment of a medical condition within a dedicated emergency department (DED).
When the Hospital cannot immediately complete an appropriate MSE, it must still assess the individual's condition upon arrival to ensure that the individual is appropriately prioritized, based on his/her presenting signs and symptoms, to be seen by a physician or other qualified medical provider (QMP) for completion of the MSE.
The hospital will provide an MSE for an individual who comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual's appearance or behavior, the individual appears to need an examination or treatment for a medical condition.

C. During an interview on 11/4/24 at 1:32PM, Patient Registration Manager (PRM) revealed, that she had been made aware of situation on 9/24/24. She spoke with P19 the same day who stated that [gender] presented to the ED on 9/15/24 between 12:00PM-2:00PM. P19 stated that they "spoke to the lady at window" and "she suggested I go somewhere else."
The PRM had security verify that P19 did present to the ED on 9/15/24 after phone call with P19. Security was able to verify that P19 had presented to the ED on 9/15/24.

D. During an interview on 11/4/24 at 2:00PM, with Chief Medical Officer (CMO) revealed, P19 was in ED on 9/23/24 and informed the MD that they were instructed to go elsewhere on 9/15/24 when [gender] presented to the ED.