HospitalInspections.org

Based on documentation and interviews, the hospital failed to ensure compliance with the requirements of 42 CFR 489.24 as evidenced by a deficiency issued at Tag #406, 42 CFR 489.24(e).

Based on review of the central log and interviews, the hospital did not enter the name of a patient who presented to the emergency department seeking medical care, on the central log in one (patient #1) of twenty-one patients reviewed. Findings include:

Documentation and interviews revealed that patient #1 is a severely disabled child and was assessed on 3/1/10 and 3/2/10 by the school nurses after being absent from school for one week and found to have an open lesion on his back, several lesions on his vertebrae, apparent weight loss and excessive weakness (he was unable to walk, feed himself, and sit up, and he was observed to continually lay in a fetal position on the cot.) Patient #1's parent brought patient #1 to the emergency department for medical care on the evening of 3/4/10. Review of the central log for 3/4/10 did not reveal that patient #1's name and status were entered on the log.

Based on review of documentation and interviews, the hospital did not provide a medical screening examination for one (patient #1) of twenty one patients reviewed. Findings include:

Documentation and interviews revealed that patient #1's parent brought patient #1 to the emergency department on the evening of 3/4/10 related to patient #1's medical problems and urgent need for medical care. During the visit to the emergency department, patient #1 was not seen by a physician, and he did not receive a medical screening examination.

A written statement, completed by nurse (E), stated patient #1's parent told nurse (E) that he did not want patient #1 to be seen by a physician on 3/4/10, but that he just wanted nurse (E) to write a note that stated it was all right for patient #1 to attend school the next day. Nurse (E) provided the parent with a note and did not enter patient #1's name on the central log, and patient #1 did not receive a medical screening examination.

Employee (E) was interviewed by phone on 4/19/10, and he confirmed that his written statement accurately described his recall of the 3/4/10 incident.

Documentation and interviews revealed that the county social services department contacted Lake City Medical Center (LCMC) on 3/5/10, and hospital staff reported that patient #1 was not seen in the emergency department on the evening of 3/4/10. Hospital staff told the county social services department that patient #1 was not logged into the computer system in the emergency department, was not seen by a physician and did not receive a medical screening examination.

On 3/5/10, patient #1's parent gave the county social services department a handwritten note that was written on the back of a prescription pad from (LCMC). The note was written by nurse (E) on the evening of 3/4/10 when patient #1's parent brought patient #1 to the emergency department. The note stated patient #1 was "vitally stable and there is no emergent/urgent need that needs our attention." On 3/5/10 social services intervened and directed an ambulance to patient #1's home, and patient #1 was transported to another hospital and admitted for numerous days due to severe malnutrition, starvation, bedsores and uncontrolled seizures.

The hospital's EMTALA Medical Screening Examination policy states "All patients presenting to the Emergency Department will receive an EMSE (Emergency Medical Screening Examination), completed by a qualified staff member, to determine if the patient has an emergency medical condition or not."