HospitalInspections.org

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Based on record review and interview, the facility failed to maintain an accurate record of each patient requesting treatment at the emergency department as defined in §489.24(b). Patient #1 presented for treatment at the facility and was not found to have been appropriately documented on the facility's emergency department central log on the date of presentation.
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Findings include:
Document Review
The facility's Rules and Regulations, last revised and implemented in May 2019, stated on page 10 of 16:
" ...EMERGENCY SERVICES
An appropriate emergency room record shall be kept for each patient receiving service in the emergency room and incorporated into the patient's hospital record. The record shall include: patient identification, time and means of arrival, pertinent history and the illness or injury, physical findings and vital signs, emergency care given to the patient prior to arrival, diagnostic and therapeutic orders, clinical observations including results of treatment, reports of procedures, tests and results, diagnostic impression, conclusion at the termination of evaluation, final disposition, condition on discharge of transfer, and any instructions given to patient or his/her family ..."
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The facility did not provide any policy specific to keeping an emergency department central log.
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The emergency department central log for the past 6 months (February 2024 through July 2024) was reviewed on 08/28/2024. A scanned copy of the emergency department central log for June 15 through June 25, 2024, was obtained, reviewed, and retained. Patient #1 was not named on the log.
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Staff #3, the Quality Director at Facility A, sent an email on 08/28/2024 at 2:30 PM and attached a screenshot that included the name and address for Patient #1 but the screenshot did not include the appropriate information for a central log entry (patient identification, means of arrival, pertinent history and nature of the illness or injury, and the date or time of arrival).
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Interviews
In an interview on 08/21/2024 at 12:51 PM with Patient #1, she stated that she presented to Facility A on 08/19/2024, but was unable to ambulate without assistance due to severe pain. Patient #1 reported that her husband went inside Facility A's emergency department to ask for assistance. Patient #1 reported a staff member from the facility described as an older lady who was tall, and light skinned with blonde hair came to the car and instructed Patient #1 to go to another hospital (Facility B).
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In an interview on 8/27/2024 with Staff #3, the Quality Director at Facility A, it was confirmed Patient #1 was not documented on the Emergency Department Central Log.
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On 08/28/2024 at 2:30 PM, an email was received from Staff #3 from Facility A and revealed the following:
"Upon further investigation of the EMTALA complaint at (Facility A), we discovered that the patient (Patient #1) had registered but then the registration was deleted when they (Patient #1) opted to seek care elsewhere. This is currently our standard practice so that a patient does not receive a bill. The patient (Patient #1) was entered via our quick registration process with a name, address, and DOB. Thus, the deleted chart would not appear in our ER log since the registration was not completed and no charges were associated with the account."

Staff #3 also confirmed that Facility A does not currently have a policy related to the emergency department central log.
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It was confirmed on 08/29/2024 via email at 8:19 AM that Staff #4, the nurse named in this anonymous complaint, fit a description given by Patient #1 during her interview on 08/21/2024 at 12:51 PM.
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