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SAINT ROSE DOMINICAN HOSPITALS - SIENA CAMPUS
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on findings at A2405, the facility failed to ensure compliance with CFR 489.24.
EMERGENCY ROOM LOG
Tag No.: A2405
Based on record review, document review and interview, the facility failed to complete an accurate emergency department central log.
Findings include:
Patient #23
Patient #23 arrived to the Emergency Department (ED) on 10/13/17 at 8:45 AM by ambulance due to a motor vehicle collision.
The patient was treated and discharged from the ED on 10/13/17 at 10:34 AM.
The facility's EMTALA (Emergency Medical Treatment and Active Labor Act) Central Log for 10/13/17, did not have Patient #23's name listed on the log.
On 11/8/17 at 11:25 AM, the Clinical Informatacist (CI) indicated when a patient was seen in the ED there were two areas to complete and place an arrival date in the electronic triage form. The section to fill in the patient arrival date and time into the ED was located in two boxes on the upper right hand corner of the electronic screen. The CI indicated if the staff did not enter an arrival date and time on the first section, then the name of the patient being treated in the ED would not carry forward into the EMTALA Central Log. The CI indicated there was no tracking process to identify how many patient names were not transferred into the EMTALA Central Log. The CI indicated the EMTALA Central Log may be incomplete and may not have all the patient names being treated in the ED.
On 11/8/17 in the morning, the CI indicated Patient #23's arrival date and time was not entered on the electronic triage form. The CI indicated since the date and time was not entered the patient's name and information was not transferred into the EMTALA Central Log.
On 11/8/17 at 4:00 PM, the ED Director obtained the names of trauma patients who were seen and treated in the ED on 10/14/17. Three trauma patients whose names were obtained were not documented on the EMTALA Central Log. The ED Director and the Clinical Innovation Specialist confirmed the arrival times were not being inputted in the electronic record system, so the names would not be transferred to the EMTALA Central Log.
On 11/8/17 at 4:00 PM, the Director of the ED and the Clinical Innovation Specialist indicated Patient #31, #32 and #33 were trauma patients seen and treated in the ED on 10/14/17. The patient names did not transfer onto the EMTALA Central Log.
The Clinical Innovation Specialist compared the ED log and the EMTALA Central log for 10/14/17. The ED log had 190 patients seen in the ED on 10/14/17 and the EMTALA Central log had 184 patients listed that were seen and treated in the ED. The Clinical Innovation Specialist did not know why the logs did not match to determine if the EMTALA Central Log was correct.