HospitalInspections.org

Based on document review, policy review, and staff interview the facility failed to follow their policy to ensure all patients presenting for treatment to the emergency room were logged on the emergency room central register log, for 1 of 21 patient records reviewed.

Findings were:

Review of the Emergency Room Central Log revealed no documentation for patient #21 who presented to the emergency room on 12/7/14 with her mother requesting to be seen in the emergency department. The patient and mother left without being treated and there was no documentation the patient even presented requesting treatment.

Facility policy entitled "Emergency Department Records" states in part "An Emergency Department Record will be initiated and patient placed on the Emergency Department Log for each encounter. A new record must be completed on every ED visit, and patient encounter recorded in the ED log. Even if these patients are discharged without treatment ... ..."

Facility policy regarding "leaving the hospital against Medical advice or leaving without being seen.." states in part "A form is provided to the hospital and to the person leaving the hospital to show documentation that person did leave on own will." No form was provided to the surveyor for patient #21.

Facility policy entitled "Emergency Department Log Maintenance" states in part "A central log will be maintained on each individual who comes to the Emergency Department seeking assistance, as defined in Sec. 489.24(b), 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. This log must contain the following information:
? Patient name
? Date
? Time of arrival
? Mode of arrival
? Age
? Sex
? Chief complaint
? Time of departure
? Patient condition upon discharge
? Disposition of patient: discharged, admitted, transferred, expired
? Name of the physician who treated the patient
? The names of those dead-on-arrival shall also be entered into the log."

Interview with staff #6 revealed the facility did not log patients in the emergency department central log when they presented to the emergency room requesting treatment. Staff #1 and #6 stated patients were entered on the log after they were registered and assigned to a bed in the emergency department. Both stated if a patient leaves before being registered there is no documentation the patient was at the facility.