HospitalInspections.org

Based upon document review and interview, the facility did not comply with all of the provisions for maintaining a central log and conducting a medical screening exam. Please reference findings under Tag A2405 and A2406.

Based on document review and interview the facility did not ensure that all individuals presenting to the Emergency Department (ED) are entered into the central log for 1 of 39 patients (Patient #1).

Findings include:

Review on 03/04/2020 of the ED log dated 01/04/2020-01/06/2020 revealed no evidence Patient #1 was entered in the log. No evidence was found to indicate a medical record was generated or that Patient #1 received a medical screening examination.

Review of policy "Emergency Medical Treatment and Active Labor Act, (EMTALA)", last revised 06/2019 revealed all presenting patients requesting examination or treatment shall be offered a medical screening examination to determine if the individual has an emergency medical condition. However, this policy does not include the requirement to enter each individual who presents to the ED on the central log.

Interview on 03/04/2020 at 03:00 PM with Staff (E), ED RN revealed on 01/05/2020 she received a phone call from an ambulance crew with report that they were bringing in Patient #1. Staff (E) immediately notified Staff (D), ED Physician Assistant (PA) who instructed her to tell the ambulance transporting Patient #1 to go somewhere else. Staff (E) called 911 dispatch and told them the ambulance crew had to divert to another hospital because Patient #1 had assaulted a female patient who was currently in their ED.

Interview on 03/05/2020 at 08:30 AM with Staff (J) ED RN Supervisor for 01/05/2020 revealed Patient #1's girlfriend was in the ED being treated. Staff (D), ED PA was notified that Patient #1 (female assault victim's boyfriend), was on his way to the ED and said, "No way, how can we keep her safe, they need to go elsewhere ". Staff (J) saw the ambulance turn around in the parking lot and leave the property but was unsure of the exact time, but indicated it was before the day shift arrived.

Interview on 03/06/2020 at 1:30 PM with Staff (A) Nurse Manager, confirmed Patient #1 was not entered into the ED log on 01/05/2020, no medical record was generated, and no medical screening was performed.

Based on interview and document review the hospital did not provide a medical screening exam for 1 of 39 patients who presented to the Emergency Department (ED) (Patient #1).

Findings include:

Interview on 03/04/2020 at 01:00 PM with Staff (D), ED Physician Assistant revealed that on 01/05/2020 Staff (E), RN told her she received report from the ambulance crew that Patient #1, the boyfriend of the assaulted female patient in the ED, was on his way to the ED, and that he had complaints of chest pain but his vitals are stable with no ST segment changes on the EKG. Staff (D), ED PA was unaware of the location of the ambulance. Staff (D) told Staff (E) ED RN to tell the ambulance that Patient #1, could not come here and needed to be diverted to another ED due to the assaulted female patient's safety, that she was the only provider with two nurses in the ED and no security on duty.

Interview on 03/05/2020 at 08:30 AM with Staff (J) ED RN Supervisor for 01/05/2020 revealed Patient #1's girlfriend was in the ED being treated. Staff (D), ED PA was notified that Patient #1 (female assault victim's boyfriend), was on his way to the ED and said, "No way, how can we keep her safe, they need to go elsewhere ". Staff (J) saw the ambulance turn around in the parking lot and leave the property but was unsure of the exact time, but indicated it was before the day shift arrived.

Review of policy "Emergency Medical Treatment and Active Labor Act, (EMTALA)", last revised 06/2019 revealed all presenting patients requesting examination or treatment shall be offered a medical screening examination to determine if the individual has an emergency medical condition.

Interview on 03/06/2020 at 1:30 PM with Staff (A) Nurse Manager, confirmed Patient #1 was not entered into the ED log on 01/05/2020, no medical record was generated, and no medical screening was performed.