HospitalInspections.org

Based on document review and interview, it was determined that for 24 patients who presented to the Emergency Department (ED) between 4/25/2021 and 9/21/2021, the Hospital failed to ensure that the ED central log was complete and included the patient's disposition.

Findings include:

1. The Hospital's policy titled, "Registration Log-Emergency Department" (dated 1/2018), was reviewed on 9/22/2021, and required, "The Log, a continuously maintained control register, provides a reference for treatment and disposition of patients presenting to the Emergency Department...Information obtained from the log may aid in planning staffing for the Emergency Department, may be used as a guide in selecting records for the evaluation of Quality Improvement, and for planning Health Care Services based on community needs...The Emergency Department Log is generated through the computer system and contains the name of the patient...complaint/diagnosis, time of departure, patient disposition..."

2. The Hospital's ED Central logs from 4/25/2021, 5/25/2021, 6/25/2021, 7/25/2021, 8/26/2021, 8/27/2021, were reviewed on 9/22/2021. The logs from these dates lacked the patients' disposition as follows:

- 4/25/2021: 3 of 84 patients
- 5/25/2021: 6 of 96 patients
- 6/25/2021: 4 of 95 patients
- 7/25/2021: 1 of 88 patients
- 8/26/2021: 6 of 86 patients
- 8/27/2021: 4 of 85 patients

3. On 9/22/2021 at 3:35 PM, an interview was conducted with the Vice President of Nursing Services (E #1). E #1 stated that the ED Log (centralized log) should be completed by the Unit Secretary and should include the patient's disposition. E #1 stated that maintaining the log aids in quality improvement.