HospitalInspections.org

Based on interview and document review, the provider failed to maintain an accurate central log for 9 of 25 entries. Specifically, logs maintained in the Emergency Department (ED) and the Labor & Delivery (L&D) Unit failed to contain accurate information regarding the mode of arrival and discharge.
Findings:
The ED and L&D logs were reviewed on 3/11/14 at 10:00 am.
The ED log book contained a list of five (5) alphabetic discharge codes, with the corresponding patient disposition descriptions, taped in the log book.
The L&D log book contained alphabetic discharge codes. The description of the patient disposition codes was not contained on the log or in the log book. The Nursing Director of Obstetrics was interviewed on 3/11/14 at 11:00 am. The Director stated that two (2) alphabetic codes were used to document patient disposition. The Director was unable to provide further explanation regarding the disposition codes.
On 3/11/14 at 1:00 pm, the Nursing Director of Obstetrics provided a handwritten sheet containing three (3) alphabetic patient discharge codes, with the corresponding patient disposition descriptions.
On 3/12/14 at 10:00 am, the L&D Unit secretary provided a listing of twenty-one (21) alphabetic discharge codes, with the corresponding patient disposition descriptions. The secretary printed a copy of discharge codes from the provider 's medical record system. The list did not have a code for admitted patients.
Provider policy "Emergency Medical Treatment and Active Labor Act", effective 2/11/14, was reviewed. The section titled "Central Log" requires that the log contain "Means of Arrival (if ambulance include name of company)" and "Disposition" information for every individual seeking emergency care. Per interview with the Quality Management Services Coordinator on 3/28/14, the policy, prior to 2/11/14, did not give specific direction to staff on the elements of the Central Log.
The following inaccuracies were noted in the logs:
L&D log entry for patient 2, who arrived on 12/11/13, documented that the patient was transported to the facility by ambulance. Review of medical record #2 did not reflect that the patient arrived by ambulance.
L&D log entry for patient 9, who arrived 12/30/13, documented that the patient was transported to the facility by ambulance. Review of medical record #9 did not reflect that the patient arrived by ambulance.
ED log entry for patient 14, who arrived 10/14/13, documented that the patient was discharged to an adult home. Review of medical record #14 documented that the patient was 21 years old, had overdosed on medication and was admitted for observation.
ED log entry for patient 18, who arrived 12/7/13, documented that the patient left against medical advice. Review of medical record #18 documented that the patient left the ED without being seen.
L&D log entry for patient 21, who arrived 8/29/13, documented the patient was discharged to an Intermediate Care Facility (ICF). On 3/26/14, the Quality Management Services Coordinator confirmed the patient was admitted to the hospital.
L&D log entry for patient 22, who arrived 8/30/13, documented the patient was discharged to an ICF. On 3/26/14, the Quality Management Services Coordinator confirmed the patient was admitted to the hospital.
L&D log entry for patient 23, who arrived 2/14/14, documented the patient was discharged to an ICF. On 3/26/14, the Quality Management Services Coordinator confirmed the patient was admitted to the hospital.
ED log entry for patient 24, who arrived 12/6/13, documented the patient's diagnosis was traumatic pneumothorax and acute renal failure. The log documented the patient was discharged to an ICF. On 3/26/14, the Quality Management Services Coordinator confirmed the patient was admitted to the hospital.
ED log entry for patient 25, who arrived 12/6/13, documented the patient's diagnosis was acute appendicitis. The log documented the patient was discharged to an ICF. On 3/26/14, the Quality Management Services Coordinator confirmed the patient was admitted to the hospital.
The ED and L&D log inaccuracies were confirmed by the Quality Management Services Coordinator on 3/12/14 at 11:00 am.