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Based on observation and interview, the facility failed to post signs which specify the rights of individuals with emergency medical conditions and women in labor.

Findings include:

1. During observational tour to the emergency room department on 01/16/24 form 10:00 AM through 11:00 AM with facility emergency room supervisor (employee #4) and medical director (employee #3) it was identified that a sign (s) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor were not posted on the entrance area
admitting area, waiting room, treatment area of the emergency room.

2. During interview on 01/16/24 form 10:20 AM the emergency room supervisor (employee #4) stated that those signs were removed by conservation staff to update them and to put them again when update is performed. During interview the emergency room supervisor (employee #4) did not specify when the signs were removed.

Based on observation, interview and record review, the facility failed to ensure all individuals presenting to the Emergency Department (ED) for evaluation were entered into the ED Central Log.

Findings include:

1. The Emergency Room (ER) Log Book was reviewed from July/2023 through January/2024 on 01/16/2024 at 8:45 AM till 11:00 AM and it provided evidence that the facility failed to ensure that pertinent patient information was appropriate documentation in the Emergency Room (ER) Log Book related to following information was left in blank in the log book: Patient Name, Age, Gender, Chief Complain, Hour of Evaluate, Hour Attendance by Physician, If Patient Refuse Treatment, If Emergency Room Refuse Attendance, Disposition, Transfer Place and Hour of Discharge of patients who visit the emergency room was not performed nor followed as reviewed on 01/16/2024 from 8:30 AM till 3:00 PM and it provided evidence that 2 out of 21 records reviewed contained incorrect documentation regarding their final disposition.

a. The patient's disposition of R.R #18 was incorrect. The patient visited the emergency room on 09/22/2023 with a diagnosis of Fever and Weakness. After the screening examination and treatment, the patient eloped from the emergency department. In the logbook the patient was documented as Against Medical Advice (AMA).

b. The patient's disposition of R.R #20 was incorrect. The patient visited the emergency room on 12/30/2023 with a diagnosis Blow from fall. After the screening examination and treatment, the patient eloped from the emergency department. In the logbook the patient was documented as Against Medical Advice (AMA).


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Facility failed to maintain registry on an emergency room central log of each individual who comes to the emergency department seeking assistance based on the following findings identified during survey procedures on 01/16/24 from 8:10 AM through 5:30 PM:

c. RR #21 is a 50 years old female, who visited the Emergency Room on 12/03/23. The patient was diagnosed with Abdominal Pain. This patient was evaluated and discharged. However it was not found registered on the emergency room log book and whether she refused treatment, was refused treatment, or whether she was transferred, admitted and treated, stabilized and transferred, or discharged. The patient was selected based on the information found documented by the emergency medical technicians on the ambulance arrival registry log, reviewed on 01/16/23 at 1:35 PM.

d. RR # 22 is a 62 years old female,who visited the Emergency Room on 12/03/23. The patient was selected based on the information found documented by the emergency medical technicians on the ambulance arrival registry log, reviewed on 01/16/23 at 1:35 PM with the emergency room nursing supervisor (employee #4). The patient was not found registered on the emergency room log book and whether she refused treatment, was refused treatment, or whether she was transferred, admitted and treated, stabilized and transferred, or discharged.

e. No policies were provided with procedures who guide the process to register patients when comes to the emergency room seeking services or assistance, when requested to the emergency room nursing supervisor (employee #4) on 10/16/24 at 2:30 PM.

2. No explanation was provided by emergency room nursing supervisor (employee #4) during interview on 10/16/24 at 2:00 PM related with the reason why those two cases are not found registered on the emergency room log book