HospitalInspections.org

Based on interview, review of the Emergency Department's (ED) Central Log, review of video footage, review of the website mapquest.com, and review of the facility's policy, the facility failed to maintain a Central Log on each individual who came to the ED seeking assistance 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 for one (1) of 20 sampled patients, Patient (P) 1.

The findings include:

Review of the facility's policy titled, "LL.029 EMTALA-Central Log," effective 09/19/2024, revealed the purpose of the policy was to identify and document everyone who either came to the Dedicated ED seeking treatment for any medical condition or presented on hospital property or premises seeking care for an emergency medical condition (EMC). Further review revealed that a log entry should be made at the first point of contact.

Review of the video footage from the facility (Facility 1) revealed P1 entered the ED doors from the parking lot at the time stamp of 07/29/2025 at 15:49 (3:49 PM). P1 was also seen at this time coming into the entry doors to the ED registration area on video footage from the inside camera. Review of a third camera footage showed P1 in the registration office at the 5:50 time mark, but there was no time stamp. P1 was observed sitting and speaking with Registration staff member (REG) 1 until 38:40 minutes into the footage. Then, the footage revealed P1 relocated to the ED waiting room. P1 was seen three times leaving the waiting room and either going to REG1's desk or the entry hallway in the ED. Per the video footage, P1 spent approximately three hours at the facility and was on the video footage as exiting the facility at 18:46 (6:46 PM).

In an interview with the Marketing Director of Facilities Management (MDFM) on 08/27/2025 at 8:30 AM, he stated the time stamp on the video footage from the cameras at the ED entrance both inside and outside were incorrect. He stated the date and time were not correct. He also stated the camera footage from the ED waiting room did not have a time stamp, and he was unsure why.

Review of the facility's ED Central Log revealed P1 was not placed on it, and there was no medical record at the facility (Facility 1) for P1.

The State Survey Agency (SSA) Surveyor made telephone calls and left voicemails for both P1 and Family Member (FM) 1 on 08/27/2025 at 3:28 PM and 3:32 PM respectively. The SSA Surveyor requested they return her phone calls to discuss P1's care at the facility (Facility 1). However, neither responded to the SSA Surveyor's voicemails.

In an interview with Registered Nurse (RN) 1, an ED staff nurse, on 08/25/2025 at 2:32 PM, she stated she was working on the day of the incident (07/28/2025), did not have direct contact with P1, but overheard P1 speaking with REG1. RN1 stated it was the facility's procedure to register the patient, the nurse would then triage, and the patient was brought back and seen for a medical screening exam (MSE) by the doctor. RN1 stated she overheard a patient come to the registration desk and ask to be admitted to the facility so she could then be discharged to a "nursing home." She stated no MSE was ever done on P1, and she was not seen in the ED. She stated P1 was asked by REG1 if she wanted to be seen, and P1 stated no because she was not sick. P1 stated she just needed to be admitted to the hospital, and her brother had dropped her off at the ED so she could get admitted to the hospital. RN1 stated P1 told REG1, if the facility could not admit her, she wanted to go somewhere that would.

In a later interview on 08/28/2025 at 8:25 AM, RN1 stated when a patient was registered by Registration staff, the patient was then entered on the Central Log. She stated nurses did not place patients on the Central Log. She stated when staff registered a patient, the patient appeared in the computer and then had a medical record. She stated per their policy, she felt the "first interaction" was registration.

In an interview with REG1 on 08/25/2025 at 2:41 PM, she stated she had worked in registration at the facility for the past 23 years. She stated, in the case of P1, no information was entered on the Central Log because she was never registered. She stated P1 was informed she had to be seen in the ED first before staff could see about getting her admitted to another hospital. REG1 stated P1 was adamant she needed to be admitted but refused to be seen in the ED. REG1 stated P1 declined to get registered and seen by the ED staff multiple times.

In a later interview on 08/27/2025 at 1:38 PM, REG1 stated, if a patient would not let her register them, they were not put on the Central Log. She stated she was unaware of the facility's policy which stated that a patient should be put on the Central Log at the first point of contact, not as part of registration.

In an interview on 08/27/2025 at 3:12 PM with RN3, an ED staff RN, she stated if a patient was not registered, they were not put on the Central Log. She stated, to be seen, a patient must register and be put on the Central Log. She stated individuals could refuse to be seen in the ED, and if they did so, they would not appear on the Central Log. She stated that was the case with P1. She stated, to her, registration would be considered the first point of contact with a patient.

In an interview on 08/27/2025 at 3:22 PM with RN4, an ED staff RN, she stated, in her opinion, registration was considered the first point of contact with any patient. She stated if there was no registration, the individual did not get put on the Central Log. When asked if P1's request to be admitted to the hospital was a first contact or not, she stated it was, and she was unable to answer why P1 was not placed on the Central Log. She stated if she had encountered a patient like P1, who only wanted to be admitted but did not want to be seen in the ED for an MSE by the doctor, she would have explained to her that she needed to be registered and seen for staff to assess if they could transfer her to another hospital for admission.

In an interview with the Director of Nursing/Quality Manager (DON/QM) on 08/25/2025 at 3:00 PM, she stated P1 was dropped off outside the ED by her brother who left her there and went to work. The DON/QM stated P1 lived with her brother and had only recently moved there to live with him. She stated P1 told staff she needed to be admitted so she could then discharge to a nursing home, and her doctor told her that was the way to get admitted to a nursing home. The DON/QM stated P1 told staff she had no medical complaints and did not wish to be seen in the ED. She stated P1 was at the facility for several hours, and she tried to figure out where she lived and what to do with her. The DON/QM stated she tried several times to get P1 to come into the ED from the waiting room so staff could assess her, but P1 would always go and sit back down in the waiting room. The DON/QM stated eventually she and other staff pooled money and called a cab from a neighboring town (the town where the facility was located did not have a cab company) to take her to another hospital, Facility 2, where P1 possibly could be admitted.

Review of the website, www.mapquest.com, revealed the approximate distance between Facility 1 and Facility 2 was 18 miles and a 21-minute drive.

Review of P1's medical record from Facility 2 revealed P1 arrived at Facility 2 on 07/28/2025 at 3:36 PM with the primary diagnosis of leg pain. Her presenting complaint was she wanted to be admitted for three days to the hospital, so she could go to the nursing home. Per the record, P1 stated she needed to go to the nursing home because she was having problems with her right knee. The record stated an MSE was performed on her at 4:13 PM, and oral pain medications of oxycodone and acetaminophen 5/325 milligrams (mg) was given at 5:16 PM and gabapentin 800 mg was given at 5:40 PM. She was discharged home where she lived with her brother at 5:49 PM in a cab paid for by Facility 2.

In a second interview with the DON/QM on 08/27/2025 at 1:45 PM, she stated she had never had a patient come to the ED and not want to be seen in the ED.

In an interview with the Chief Nursing Officer (CNO) on 08/25/2025 at 3:13 PM, she stated P1 presented at the ED asking to be admitted to the facility, but she would never let staff register her, triage her, or perform an MSE. She stated that was why P1's name would not be on the Central Log. The CNO also stated it was the hospital's practice not to place anyone on the Central Log unless they were registered.

The SSA Surveyor made telephone calls and left voicemails for the facility's Medical Director three times, on 08/28/2025 at 8:45 AM, 9:00 AM, and 9:45 AM. The voicemails asked him to return a phone call to the SSA Surveyor to discuss P1's care. Also, on 08/28/2025 at 8:45 AM, a text message was sent asking him to call to discuss P1. However, he did not respond to the SSA Surveyor's voicemails or text.