HospitalInspections.org

Based on interviews and review of policies and procedures, Emergency Department (ED)logs and intake records it was determined the hospital failed to maintain a central log to include each individual who came to the ED sseking medical assitance for 1 of 25 sampled patients.

The findings included:

A review of the facility's Policy and Procedure, titled, "EMTALA Medical Screen" effective 9/04 last reviewed 08/08 specified in part, " Central Log is a log that the hospital is required to maintain on each individual who comes to its emergency room or any location on the Hospital Property or Premises seeking assistance and the disposition of each individual, whether or not he or she refused treatment, or whether he or she was transferred or discharged. The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital Property or Premises seeking care for an emergency medical condition."

Review of an Intake/Referral form regarding Patient #1 completed in the ED by psychiatric unit staff on 07/08/10 revealed the patient was assessed at 2000 hours, a physician was contacted and the patient was referred to a psychiatric hospital. Review of the hospital's ED log from 01/10 through 07/20/10 revealed no entry to indicate the presence of Patient #1 during that period. patient #1's name did not appear on the ED central log. The facility failed to maintain a central log on patient #1, an individual who was seeking medical assistance.


Interview with RN #1 on 07/22/10 at 12:50pm revealed that Patient #1 presented to the ED while the RN was on duty. He further stated that the patient was a "walk-in" and was never registered to the ED.


Interview on 07/21/10 at 12.00pm with the Director of the ED revealed that, when a patient arrives ambulatory to the ED, he/she presents to the clerk at the registration window who is to do a "rapid admit" in which the clerk obtains the patient's name, contact information, name of family practitioner, and chief complaint (if possible). The patient would then see a nurse for triage where vital signs and a general health assessment would be done and a medical history taken. A mental status exam would also occur here if indicated. A chart is to be assembled, a physician notified and the physician would then see the patient. A medical screening examination would be done at this time. The director further stated that persons often came to the ED who planned to go to the psychiatric unit as "direct admits". They would be medically evaluated, and, if needed, stabilized, before being admitted to the psychiatric unit. If a patient presented with suicidal or homicidal ideation, he/she would be placed in a treatment room in front of the nurses station and medically evaluated by a physician. Then, someone from the psychiatric unit would come to evaluate them.

Interviews on 07/21/10 at 3:45pm and 4:25pm with ED registration clerk #1 and clerk #2 revealed that all patients seen in the ED should have information entered into the computer system from a "short form". They explained that when a patient came for admission to the psychiatric unit through the ED, and the ED was notified by the psychiatric unit ahead of their arrival, a short (intake) form would be done. Then, a more extensive "long form" would be completed upon admission to the unit. They said that no one should leave the hospital without being registered.

Interview on 07/21/10 at 3:30pm with the Supervisor of the ED Registration revealed that anyone who presented to the registration window was to have a "short form" completed (with name, social security number, date of birth, chief complaint and the time). This information automatically went into the ED log. She stated that registration clerks were trained to do this on their first two days on the job. She said patients were to be registered even if they left before being seen and she was not aware of anyone not getting registered. However, the Supervisor stated that if a patient was "triaged" by the psychiatric unit, unit staff would return to the ED registration and give them a room number if the patient was to be admitted. If there were no beds available on the psychiatric unit, staff would either tell registration that the patient should be seen in the ED or they would refer the patient elsewhere. The Supervisor added that, in the case of psychiatric unit staff referring a patient elsewhere, the ED registration clerk would not have entered them into the computer.

Interview on 07/22/10 at 10:00am by phone with registration clerk #3 revealed that, if a patient presented to the registration window, requested to be admitted to the psychiatric unit and was not expected by unit staff for direct admit, the clerk called the psychiatric unit. The clerk said that if the psychiatric unit had not yet evaluated the patient, she did not register the patient. Further, she said if a patient needed admission but no bed was available, or the patient was not given a diagnosis for admission, the patient's name would not be entered into the computer and would not print out on the log. Upon evaluation by the psychiatric unit, the patient could be released, not return to her, and she would not know it.

The facility to ensure that their policy and procedure was followed to ensure that on July 8, 2010 Patient #1 was entered on the Central Log .