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Based on review of facility policy and procedure, Emergency Department (ED) central logs, and interview with facility staff, it was determined the facility failed to maintain an ED central log which included the disposition of each patient who presented to the ED for care.

Findings include:

Policy and Procedure Directive
Subject: EMTALA
Date Reviewed: 03/18

"II. Purpose:
The purpose of this policy is to set forth policies and procedures for Hospital's use in complying with the requirements of the Emergency Medical Treatment and Labor Law Act (EMTALA).

V. Procedures:

C. Central Log

1. The Hospital must maintain a central log of individuals who "come to the emergency department," and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE (Medical Screening Examination)."

On 7/5/18 at 8:00 AM the ED central log was requested for the time period of 1/1/18 to current date of the survey.

Review of the ED central log on 7/5/18 at 10:45 AM revealed multiple log entries with no disposition of the patient recorded. This was discussed with Employee # 1, Interim Chief Nursing Officer, who reviewed the logs and stated she would "check on it."

EI # 1 returned in the afternoon of 7/5/18 and reported there was a problem with (name of vendor) and the company was looking into the matter.

On 7/9/18 at 12:00 PM the ED central log was requested for the period of 1/15/18 to 1/31/18.

Review of the ED central log for 1/15/18 to 1/31/18 revealed 1443 patient entries. Sixty four entries had no disposition documented.

An interview conducted on 7/9/18 at 5:00 PM with EI # 1 confirmed the central log failed to include the disposition of each patient.