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Based on interview and record review, the facility failed to ensure that emergency medical services were provided in accordance with CFR §489.24, the regulations for the Emergency Medical Treatment and Active Labor Act (EMTALA) when:

1. The Emergency Department log was incomplete for one of 23 sampled pateints (Patient 16) (refer to C 2405).

2. There was no triage assessment documented for one of 23 sampled patients (Patient 20) (refer to C 2406).

Based on interview and record review, the facility failed to maintain a complete ED (Emergency Department) daily log (a list of patients who seek care in the ED) for Patient 16. This failure resulted in incomplete patient records, and unnecessary confusion as to the status of Patient 16.

Findings:

Patient 16's medical record was reviewed. Patient 16 arrived to the facility's ED on 4/15/24 at 10:57 am, with a complaint of high blood pressure (a condition in which it takes more force for the heart to pump blood through the arteries). A review of Patient 16's record indicated missing documents.

A review of the Emergency Room (ER) Register, a log in which ED staff handwrite data on all patients that arrive to the ED including date and time of arrival, the time roomed, the mode of arrival, patient name and date of birth, age and sex, the physician seen, their chief complaint, treatments/diagnostics performed, the diagnosis at discharge, and their disposition (or destination), among other data. A review of the log for the date of 4/15/24 indicated that Patient 16 had not been written into the Register.

During a concurrent interview and record review, on 10/8/24 3:50 pm, the Chief Nursing Officer (CNO) stated that not all data entered into the computerized documentation system (CPSI Evident) would populate onto the ED daily log (the electronic form of the ER Register), and the ER Register was maintained as a backup to fill in gaps such mode of arrival or disposition.

In a follow up interview on 10/9/24 10:40 am, the CNO confirmed that for an unknown reason Patient 16 was not written into the ER Register.

During a concurrent interview and record review of an Accounts Receivable, conducted on 10/9/24 at 11:55 am, the Lead Health Information Specialist stated that she had looked into Patient 16's ER visit on 4/15/24. It indicated that Patient 16 had registered, and then left without being seen by a physician or nurse less than an hour (53 minutes) after registering.

Based on interview and record review, the facility failed to ensure Patient 20 was triaged (a clinical assessment of a patient's presenting signs and symptoms in order to prioritize when a medical provider will see a patient) by a Registered Nurse (RN) upon arrival to the Emergency Department (ED).

This failure had the potential for negative health outcomes for Patient 20 as triage is part of the screening process in determining whether or not an individual has an emergency medical condition (EMC), and its acuity.

Findings:

A review of an undated facility policy titled, "Triage, Emergency Room," indicated a qualified RN is to triage all patients presenting to the ED for care.

Patient 20's medical record was reviewed. Patient 20 arrived to the facility ED on 4/22/24 and was registered at 5:01 pm, with a chief complaint of suicidal ideation (SI), a thought process with a spectrum spanning from considering no longer being alive, to an active plan to end one's life.

A review of a ED Provider note dated 4/22/24 at 6:24 pm, indicated Medical Doctor (MD) A documented in history of the present illness for Patient 20 an additional diagnosis, that of bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function).

During a review of Patient 20's medical record indicated on 10/9/24, no nursing triage was found in the ER documentation.

During a concurrent interview and record review, with the Chief Nursing Officer (CNO) conducted 10/9/24 2:28 pm, the CNO stated a nursing triage was not done for Patient 20. CNO stated that every patient should be triaged, audited triage records monthly, and that the absence of this triage would be flagged.