HospitalInspections.org

Based on document review, video review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure compliance with 42 CFR 489.24. This has the potential to affect all patients who present to the Emergency Department (ED) seeking treatment, currently an average of 6 patient visits daily.

Findings include:

1. The CAH failed to ensure patients were documented on the ED central log. See C- 2405.

Based on document review, video review, observation and staff interview it was determined the Critical Access Hospital (CAH) failed to ensure all patients who present to the Emergency Department (ED) seeking treatment are recorded in the ED central log. This has the potential to affect all patients who present to the Emergency Department (ED) seeking treatment, currently an average of 6 patient visits daily.

Findings include:

1. The complaint log (dated 4/7/2020 to 4/20/2021) was reviewed on 4/20/2021 at approximately 11:20 AM The complaint log included 2 patients listed that presented to ED for treatment (Pt #1 on 2/26/2021 and Pt #20 on 10/7/2020).

2. The event log for 4/2021 was reviewed on 4/20/2021 at approximately 11:27 AM and included an event for both Pt #1 and Pt #20.
a. Pt #1 presented to the ED grounds with the chief complaint of nosebleed and COVID 19 positive.
b. Pt #20 presented to the ED grounds with the chief complaint of problems after surgery.

3. The ED log (dated 10/20/2020 to 4/20/2021) was reviewed at 11:25 AM. The log lacked the names of Pt #1 and Pt #20.

4. A phone interview was conducted on 4/21/2021 at approximately 11:45 AM with the Registered Nurse (E# 3). E#3 stated "remembered taking care of (Pt #1 and Pt #20). Neither pt came into hospital for registration. (Pt #1's) sibling was upset and thought (E#3) told them wouldn't take care of pt due to positive COVID 19." E#3 stated "explained to sibling (of Pt #1) pt could be seen here with positive COVID 19 but doesn't know if sibling heard it. Pt left with sibling without coming into hospital for registration or treatment. E#3 included for Pt #20 the spouse was upset and pt didn't come into hospital for registration or treatment. E#3 stated "didn't get a chance to get the patient names before they left the parking lot."

5. During an interview with the Senior Nursing Officer (E#2) through out the survey on 4/20/2021 at approximately 11:00 AM to 4/21/2021 at approximately 3:30 PM, E#2 stated, "All patients are entered into the ED log that have been registered in the computer... the clerk that works the next day looks at charts from previous day and enters them into the log by using those charts." E#2 verified Pt #1 and Pt #20 did not get registered, therefore neither were entered into the ED Central log. E#2 stated there was no video of the encounter for Pt #20, as the incident was greater than 30 days ago and the video tape records over themselves every 30 days. There is no video for outside the ED in the parking lot for Pt #1 and Pt #20.

6. On 4/22/2021 at 8:30 AM a recording of Pt #1 was presented by E#2 and reviewed. The video recording dated 2/26/2021 shows the following:
a) 1919 (7:19 PM) showed a person (identified by E #2 as sibling to Pt #1) coming to ED entrance and greeted by the registrar.
b) 1920 (7:20 PM) sibling reading signs by ED.
c) 1922 (7:22 PM) sibling pushed button again (button outside of ED door to get ED staff to let patient or visitor inside).
d) 1923 (7:23 PM) Registered Nurse (identified as E#3 with PPE on- personal protective equipment) met sibling and walked out with sibling.
e) 1925 (7:25 PM) E#3 walked back into the ED alone without PPE on. Pt #1 and sibling were not observed to enter the building.
f) The video was watched with E#2 and E#2 reaffirmed both Pt #1 and Pt #20 were not entered on the ED log.