HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure a medical screening examination was performed. See A-2406.

A. Based on document review and interview, it was determined that for 1 of 20 patients (Pt. #1) presenting to the emergency department for evaluation, the Hospital failed to ensure the log was maintained by placing all patients on the central log.

Findings include:

1. The Hospital's policy titled, "Emergency Department (ED) Log (4/22)" was reviewed on 7/11/2023 and required, "A central log will be maintained on each individual who comes to the emergency department seeking assistance."

2. Pt. #1 presented to the Hospital's ED on 4/22/2023 at 11:21 PM. Pt. #1 was registered and waited in the waiting room for approximately 1.5 hours. Pt. #1 left the Hospital without being seen on 4/23/2022 at 12:43 AM. Pt. #1 was never entered into the ED log.

3. During an interview with the Chief Nursing Officer (E #3) on 7/11/2023 at 10:00 AM, E#3 stated that the Hospital had received a grievance regarding Pt. #1. Pt. #1 did present to the ED on 4/22/2023, had a quick registration and was requested to wait in the waiting room. The patient left, and since the patient was never seen by medical staff, the registrar deleted the encounter. E#3 stated, "This was a mistake. When the encounter was deleted, the patient was deleted from the log."


B. Based on document review and interview, it was determined that for patients who left without being seen (LWBS), the Hospital failed to ensure the ED (emergency department) central log included the disposition for each individual who comes to the ED..

Findings include:

1. The Hospital's policy titled, "Emergency Department (ED) Log (4/22)" was reviewed on 7/12/2023 and required, "A central log will be maintained on each individual who comes to the emergency department seeking assistance. ... The log will include the following: ... Disposition."

2. The ED logs from 1/1/2023 to 7/11/2023 were reviewed on 7/12/2023. No LWBS patients' dispositions were identified on the logs.

3. Samples of patients from the log with the disposition space blank included:
- Pt. #18 - Arrived to ED on 4/8/2023 at 6:44 AM - documented in nursing notes on 4/8/2023 at 6:59 AM, "Patient left without being seen."
- Pt. #19 - Arrived to ED on 7/5/2023 at 4:44 PM - documented in nursing notes on 7/5/2023 at 5:33 PM, "Left without being seen."
- Pt. #20 - Arrived to ED on 6/10/2023 at 11:05 PM - documented in nursing notes on 6/10/2023 at 11:11 PM, "LWBS."

4. During an interview on 7/12/2023 at approximately 9:30 AM, the chief nursing officer (E#3) stated that the computer system does not allow for a disposition for LWBS. The nurse must write left without being seen in another area of the chart. E#3 stated, "That area of the chart does not drop to the ED log, leaving the disposition blank. The data is available through a specific computer search for LWBS." E#3 stated that the log should show the disposition.

Based on document review and interview, it was determined that for 1 of 17 (Pt. #1) patients reviewed who presented to the emergency department (ED), the Hospital failed to ensure a medical screening examination was performed.

Findings include:

1. The Hospital's policy titled, "EMTALA Guidelines (12/21)" was reviewed and required, "[Hospital] will provide an appropriate medical screening examination to all patients presenting the the [Hospital]."

2. The Hospital's policy titled, "Registration of Patient's in the Emergency Department (4/22)" was reviewed on 7/11/2023 and required, "The admitting department clerk will immediately notify the triage nurse if any individual complains with the following: chest pain . ..."

3 The ED log was reviewed and Pt. #1 was not included in the log. A request for a clinical record for Pt. #1 was made. The Chief Nursing Officer (E#3) stated that Pt. #1 did not have a clinical record.

4. During an interview on 7/11/2023 at 10:00 AM, E#3 stated that the hospital had received a grievance regarding Pt. #1. The grievance included that Pt. #1 came to the hospital with chest pain, was registered ad never seen. Pt. #1 left and went to another hospital. A video review showed that Pt. #1 did present to the ED on 4/22/2023, had a quick registration and was requested to wait in the waiting room. The patient left and since the patient was never seen by medical staff, the registrar deleted the encounter. E#3 stated, "This was a mistake."

5. A video review was conducted on 7/11/2023 at 11:55 AM. Pt. #1 presented to the ED on 4/22/2023 at 11:21 PM. Pt. #1 was registered and waited in the waiting room for approximately 1.5 hours. Pt. #1 left the hospital without being seen on 4/23/2022 at 12:43 AM. Pt. #1 was never triaged or provided any services.

6. Pt. #1 presented to another hospital on 4/23/2023 at 8:40 AM with complaints of heart fluttering/racing with a headache. The workup at Hospital B was negative for cardiac condition and Pt. #1 was discharged.

7. During an interview on 7/12/2023 at 9:00 AM, E#3 stated that Pt. #1 should have been triaged and had a medical screening exam, especially if complaining of chest pain. E#3 stated that since this investigation, the following staff have received EMTALA education with 100% completion: emergency room registered nurses, ED behavioral health intake staff, ED registrars, public safety officers, and emergency room physicians (verified by attendance sheets). The patient disposition choices have been corrected in the computer to allow for 'left without being seen', for better tracking of patients. Registrars no longer have the capability to delete encounters.