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A. Based on review of the ED log and 29 medical records, it was determined that the log entries, for 5 of 29 medical records (Medical Records #10, #19, #20, #21 and #23) reviewed, contained inaccurate information.

Findings include:

1. Review of the ED log for 12/4/12 indicated the disposition of Patient #10 as "Against Advice." Review of Medical Record #10 indicated the patient left without being seen.

2. Review of the ED log for 1/5/13 indicated the admission time for Patient #19 as 11:36AM and the discharge time as 11:36AM. Medical Record #19 indicated the patient presented to the ED at 7:00AM.

3. Review of the ED log for 1/5/13 indicated the admission time for Patient #20 as 11:55PM and the discharge time as 11:55PM. Medical Record #20 indicated the patient presented to the ED at 7:30AM.

4. Review of the ED log for 11/3/12 indicated the disposition for Patient #21 as "Against Advice." Review of Medical Record #21 indicated the patient left without being triaged.

5. Review of the ED log for 11/3/12 indicated the disposition for Patient #23 as "Against Advice." Review of Medical Record #23 indicated the patient left without being seen.


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B. Based on review of the L&D triage log, it was determined that the facility failed to maintain a log that reflects the final disposition of all patients.

Findings include:

1. On 3/19/13 at 11:00 AM, review of the L&D Triage log in the presence of Staff #8, lacked documentation of the final disposition of patients that were treated and discharged. Patients that were admitted had 'admitted' written next to their entry on the log. However, the log failed to reflect whether or not patients listed were discharged or transferred. Per Staff #8, patients that are discharged have only a discharge time written next to their entry on the log.

2. Review of Medical Records #11, #12, #13, #14, #15, #16 and #17 indicated that each patient arrived to the L&D triage, were treated and discharged. The corresponding L&D triage entries for these patients lacked a final disposition of discharge.

a. Medical Records #13, #14 and #16 lacked evidence of a discharge time on the log indicating the patient was discharged, as per facility practice, or as indicated in each of the medical records.

A. Based on document review, it was determined that the facility failed to ensure that a medical screening evaluation of all patients presenting to the ED, was performed by qualified medical personnel.

Findings include:

1. Patient #27, under the direction of his/her primary physician, presented to the ED complaining of dizziness following a fall, to have a CT scan, to rule out a transient ischemic attack. Patient #27 presented to the ED on 10/17/2011 at 3:28PM and triaged by a nurse at 3:54PM. The patient was reassessed by a nurse at 6:57PM. Documentation in Medical Record #27 indicated the patient left the ED on 10/17/2011 at 8:24 PM without having been evaluated by qualified medical personnel.


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B. Based on review of L&D Triage medical records and staff interview, it was determined that the facility failed to provide a medical screening exam to one of seven patients reviewed (Medical Record #14).

Findings include:

1. On 3/20/13, review of Medical Record #14 indicated, per the OB Triage form, that Patient #14 arrived to the L&D Triage area on 11/1/12 at 1:15 PM, complaining of "N & V (nausea and vomiting) X 2 WKS (weeks), rule out gallbladder". Patient #14's EDC was 2/7/13.

a. There was no evidence in Medical Record #14 of a MSE by a LIP. This was confirmed by Staff #13 and Staff #15.

2. Per the Discharge Documentation forms, Patient #14 was discharged on 11/1/12 at 18:40.