HospitalInspections.org

Based on review of 30 medical records, policies and procedures, and other pertinent documentation, and observations in the Emergency Department (ED) on 12/2/20, the hospital failed to adhere to EMTALA policies and procedures of ensuring that the hospital's ED log reflected accurate and complete information about all individuals who presented to the hospital seeking emergency services.

Surveyors reviewed the hospital's policy titled "Emergency Medical Treatment and Labor Act (EMTALA) Administrative Policy (last revised 06/2020). Under the section "Procedure: a) Centralized log", the policy stated: "A log must be available from the emergency department on each individual who seeks assistance, with information about whether he/she refused treatment, transferred, admitted and treated, stabilized and transferred, or discharged. This information must be retained for a minimum of six months."

Patient #1 (P1) was transported to the hospital's ED by county-operated ambulance with symptoms of chest pain. The ambulance crew alerted the hospital ED staff of P1's symptoms and impending arrival to the hospital via radio communication. Upon arrival to the hospital, P1 was assessed inside the ambulance by an ED provider who informed P1 of the need to transfer to another facility for emergent specialized treatment. Per the ED provider's note, P1 was deemed medically stable and agreed to the transfer. P1 arrived at the recipient hospital approximately 20 minutes later and was treated without incident.

Surveyors reviewed the hospital's ED log for the day when P1 presented to the ED; however, P1's name, visit, and disposition information could not be found on the log.