HospitalInspections.org

Based on review of documentation and staff interview, the hospital failed to maintain any written entry in its central log for 1 of 68 individuals (Individual #30) who came to the Emergency Room (ER) seeking medical assistance on 01/08/11. The findings are:

A. On 01/11/11 at 3:10 pm, during a telephone interview, Individual #30 stated that she had gone to the hospital ER to be seen because she had fallen a couple of days before and now she had severe neck pain and she could not move her head. When she had presented herself to the ER Registration desk, she told the person there that she had severe neck pain and requested to be seen.

B. On 01/11/11 at 2:30 pm, the Interim ER Director, the ER Clinical Services Director, the Chief Nursing Officer and other Administrative staff were asked to provide a list of all individuals that sought services from the ER for the past six months. The hospital provided the "ProMed [the software used by the ER staff to document those individuals seeking assistance at the ER]" list as the list of all individuals that came into the ER for services.
1. Review of the hospital's ER and Fast-Track logs for 01/08/11 revealed Individual #30 was not on the list.
2. On 01/13/11 at 10:30 am, during the Exit Interview, the ER Clinical Services Director confirmed that Individual #30 was not on the lists provided.

C. Review of the ER video from camera #2 for 01/08/11, by two surveyors, revealed the following information:
1. At 2:05:50 pm, Individual #30 could be seen entering into the ER.
2. At 2:06:21 pm, Individual #30 could be seen at the ER Registration desk and talking to a staff member behind the desk.

D. On 01/12/11 at 1:15 pm, during an interview, ER Registration Clerk #1 stated that she recalled talking to Individual #30 on the afternoon of 01/08/11. When she was shown a video still of Individual #30 standing at the ER Registration desk, she confirmed that this was the person she remembered. She acknowledged that she did not collect any information, but stated that she should have collected the appropriate information and entered this into "ProMed," which functioned as the central log.

E. On 01/12/11 at 1:45 pm, during an interview, the ER Charge Nurse confirmed she was the Charge Nurse on 01/08/11. She stated that all individuals should be entered into the ER central log when they come into the ER to be seen.

F. Review of the hospital's policy and procedure titled, "Emergency Department Registration, " revised July 2010, revealed the policy, "... registration process may include requesting basic patient demographic information...," and the procedure read, "All patients presenting to the Emergency Department will be entered into ProMed (Presentation board)."

Based on documentation review and staff interview, the hospital failed to provide a medical screening examination for 1 of 68 individuals (Individual #30) who sought services from the Emergency Room (ER) on 01/08/11. Individual #30's complaint upon her appearance at the ER was severe neck pain and inability to move her head. The findings are:

A. On 01/11/11 at 3:00 pm, during an telephone interview, Individual #30 stated that she had gone to the hospital ER to be seen because she had fallen a couple of days before and now she had severe neck pain and was unable to move her head. When she arrived at the ER Registration desk, she told the person there that she had severe neck pain and requested services.

B. Review of the ER video from camera #2 for 01/08/11, by two surveyors, revealed the following information:
1. At 2:05:50 pm, Individual #30 could be seen entering into the ER.
2. At 2:06:21 pm, Individual #30 could be seen at the ER Registration desk and talking to a staff member behind the desk.

C. On 01/12/11 at 1:45 pm, during an interview, the ER Charge Nurse confirmed she was the Charge Nurse on 01/08/11. She stated that Individual #30 should have been given a medical screening examination since she was complaining of severe neck pain after a fall.

D. Review of the hospital's policy and procedure titled, "Emergency Department Registration, " revised July 2010, read, "G. Medical Screening Examination/Stabilization - A medical screening examination process will be provided to all patients presenting to the Emergency Department requesting medical treatment."