HospitalInspections.org

Based on interview, record review, and review of video footage, the facility failed to ensure maintenance of the central log for patients presenting to the emergency room as evidenced by not registering Patient #5's visit on September 12, 2018.

Findings included:

A review of the "Medical Staff Bylaws (08/16)" documented an appropriate emergency department record or log should be kept listing every person who presented him/herself or was brought to the Emergency Department (ED) for treatment or care.

A review of the policy titled, "EM001 Hospital Compliance with EMTALA (05/16)" documented a log would be maintained by the hospital on each individual who came to the emergency department or any location on the hospital property seeking emergency assistance. The policy was a corporate policy and failed to designate that the policy applied to the hospital being surveyed.

A review of the policy titled, "EM003 EMTALA - Central Log (05/16)" documented an individual should be recorded in the Central Log even if he/she leaves the hospital before triaged or receiving a MSE. The policy was a corporate policy and failed to designate that the policy applied to the hospital being surveyed.

On 09/24/18 at 1:30 pm, the surveyors observed video footage from 09/12/18 at 9:05 am to 4:47 pm and 8:17 pm to 9:23 pm. The video showed 18 patients presenting to the ED registration window. The video patients were compared with patients on the ED logs for the same time frames. There were 17 patients recorded on the log for the timeframe. The times of the video recording, and the times documented in the ED logs matched 17 out of 17 patients. Patient #5 was not documented on the ED log.

On 09/24/18 at 1:30 pm, Staff A stated that Patient #5 did not check-in, and he/she saw no paperwork completed.

On 09/26/18 at 9:15 am, Staff B stated he/she remembered Patient #5, did not get his/her name, did not document him/her on the ED Log, and did not make the nurses and physician aware of Patient #5's presentation/departure. Staff B stated Patient #5's chief complaints were stomach pain and vomiting, and the man accompanying Patient #5 stated the patient was in a lot of pain.

Based on interview, record review, and review of video footage, the facility failed to perform and document a medical screening examination to determine if there was an emergency medical condition for Patient #5.

Finding included:

On 09/24/18 at 1:30 pm, in the presence of the Quality Director, the surveyors reviewed the ED video footage from the cameras [no audio] at the registration window and ED entrance for 09/12/18 at and around 9:52 pm, Patient #5 was seen presenting to the ED registration window and three minutes later, was seen leaving the ED. The hospital provided no paperwork regarding this patient's ED visit.

[It was reported: Upon leaving the hospital being surveyed, Patient #5 went to another facility and was diagnosed with myocardial infarction (heart attack) on 09/13/18 at 12:16 am.]

A review of the ED Log for 09/12/18 showed no documentation of the presentation of Patient #5 at 9:52 pm.

A review of a total sampling of 34 medical records of patients presenting in ED from 03/18 to 09/22/18 showed 21 (Patients #1-20 and Patient #22) of 21 patients with the diagnosis of chest pain received a MSE. The review showed three (Patients #5, 21, 23) of 23 patients presenting to the ED on 09/12/18 left without being seen, and two (Patients #21, 23) of three were documented in the ED Log.

A review of the "Medical Staff Bylaws (08/16)" documented each person presenting to the hospital requesting emergency treatment would receive a MSE.

A review of the policy titled, "EM001 Hospital Compliance with EMTALA (05/16)" documented a MSE would be offered to any individual who came to the ED, and provided within the capability of the ED including the use of available ancillary services. The policy was a corporate policy and failed to designate that the policy applied to the hospital being surveyed.

A review the policy titled, "Chest Pain, ACS [Acute Coronary Syndrome], MI [Myocardial Infarction] l (08/17)" documented an EKG (electrocardiogram) should be performed within the first 10 minutes of arrival for patients presenting with chest pain, and the physician should review the EKG immediately.

On 09/25/18 at 10:44 am, Staff C, CNO, stated the staffing plan for the 7 pm to 7 am shift in the ED was one receptionist and two RNs. Staff C stated if other staff were needed, they would be called into work. Staff C stated there was a House Supervisor on the 7 pm to 7 am shift on Fridays, Saturdays, and Sundays only.

A review of the staffing schedule for Wednesday 09/12/18 showed one receptionist (Staff B) and two RNs (Staff G and Staff I) for the 7 pm to 7 am shift in the ED.

A review of the ED Logs and medical records showed on 09/12/18 at 9:52 pm when Patient #5 arrived at the ED, there were eight patients (Patient #26- Patient #33) occupying eight of the nine ED exam rooms. Patient #32 was discharged at 9:35 pm, which opened an additional exam room.

On 09/25/18 at 11:45 am, after reviewing the number of patients in the ED at the time of Patient #5's arrival, Staff G stated if a receptionist would have notified him/her that a patient presented with chest pain, he/she would have moved the patient with leg pain back in the waiting room to triage the patient with chest pain in the exam room. Staff G stated EMTALA said a person has the right to have a medical screening.

On 09/25/18 at 9:40 am, after reviewing the number of patients in the ED at the time of Patient #5's arrival, Staff F stated upon notification of the patient presenting to the ED with chest pain or other indications of urgency, he/she would expect the nursing staff to evaluate the patient immediately. Staff F stated if the nurses were unavailable, he/she would take the patient into the triage room to do a quick two minute assessment and get an EKG as soon as possible.

On 09/25/18 at 12:15 am, Staff H stated patients who present to the ED with chest pain were seen right away, the doctor was notified, and an EKG was completed. Staff H stated an aspirin would be given if indicated per order. He/She stated "time is tissue" [delay in evaluation and treatment could result in cardiac tissue damage]. He/She stated clerical activities were secondary to treating the patient's chest pain and all resources were utilized for managing chest pain.