HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure patients presenting to the ED for treatment were documented in a central log for 1 (Patient #21) of 21 ED patients reviewed. This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum.

Findings:

On 06/15/22, OSDH received a self-report regarding potential noncompliance with Emergency Services. It alleged Patient #21 came to the ED seeking services on 05/01/22 and was not entered into the ED log.

The surveyors reviewed a policy titled "EMTALA Compliance", which read in part:

"The hospital will maintain a central log on each individual who comes to a DED seeking assistance, which will contain the individual's disposition status..."

The surveyors reviewed a document titled "EMTALA Findings/Corrective Action summary", which read in part:

"On Sunday May 1, 2022, at approximately 0043 CST, a 37 yr. old female (Complainant) entered (name and address of the facility)."

"Within seconds of her arrival, she approached registration and then returned to the same lobby chair...in attempts to become more comfortable."

"At 0104, (Staff J) approached the Complainant and appeared to be interaction, as (Staff J) was writing on the registration paperwork, but she eventually put the paperwork down and left the ED lobby."

The surveyors reviewed the facility's ED logs for April and May 2022. Patient #21 was not documented in the facility's ED logs.

During an interview on 06/17/22, Staff C stated all patients coming to the ED should be documented in the ED log.

Based on record reviews and interviews, the hospital failed to ensure a MSE was performed for all patients presenting to the ED requesting a MSE. This failed practice had the potential to result in a delay of treatment and deterioration of the patient's condition for 1 (Patient #21) of 21 patients reviewed that presented to the ED for a MSE.

Findings:

On 06/15/22, OSDH received a self-report regarding potential noncompliance with Emergency Services. It alleged Patient #21 came to the ED seeking services on 05/01/22 and was not given a MSE.

The surveyors reviewed a policy titled "EMTALA Guidelines", which read in part:

"All patients presenting to our Hospital's Emergency Department and seeking care...must be accepted and evaluated for treatment."

The surveyors reviewed a document titled "EMTALA Findings/Corrective Action Summary", which read in part:

"On Sunday May 1, 2022, at approximately 0043 CST...(Complainant) approached the registration desk and asked to be seen...informed registration she had back pain."

"As observations continued, during the time between 0045 CST until 0104 CST...three staff members approached the Complainant as she lied [sic] on the floor..."

"Between 0104 CST and 0127 CST, the Complainant remained on the (lobby) floor...at 0120 CST EMS arrived at the hospital...by 0127 CST, EMS left the building and transported the Complainant to (a different facility)."

"On May 13, 2022...during the telephonic interview with (Staff D)...he did acknowledge the Complainant mentioned her back pain to him."

"On May 19, 2022...an additional call was made to (Staff J) to confirm the Complainant asked for assistance, which was acknowledged yes."

There was no documentation to support the patient was provided a MSE for her reported back pain.

During an interview on 06/17/22, Staff C stated all patients coming to the ED should be given a MSE.