HospitalInspections.org

Based on record review, observation and interview, the facility failed to follow hospital policy and maintain an accurate, complete log of patients presenting to the Emergency Department (ED) in 1 of 1 ED log reviewed in a total sample of 1.

Findings include:

In interview with ED Director C at 9:30 AM on 5/31/2023 when asked about expectations for documentation in the ED log stated, "It is expected that the log is complete and accurate." Questioned regarding error correction in the log, ED Director C stated that, "the ED follows the facility policy for error correction."

Review of facility policy titled "Health Information" #43.44 dated 1/6/2023 revealed, "...Policy: All hand written entries in the medical record shall be legible, dated (including year), timed (military time) and authenticated. This rule applies to physicians, nurses, and all other staff who make entries in the medical record...A. Corrections Procedure - draw a single line through each line or word of the inaccurate entry making sure it is still legible (errors should never be obliterated, date, time and initial the error...Use of correction pen, liquid paper or any white out substance is NOT acceptable..."

Review of the ED Log revealed the following: The paper log titled, "Emergency/Urgent Care Outpatient Central Log" had the following columns: time, mode, patient's name/sticker, complaint, disposition, time, mode, and Pt. (patient) type. Review of the logs from December 2022 - May 2023 revealed the following number of entries which were crossed or scribbled over or whited out:
December 2022- Complaint: 4, Disposition: 3, Time: 8, Mode: 5, Type: 4,
January 2023- Complaint: 2, Disposition: 4, Time: 14, Mode: 4, Type: 4,
February 2023 - Complaint: 4, Disposition: 3, Time: 8, Mode: 5, Type: 4,
March 2023 - Complaint: 8, Disposition: 13, Time: 23, Mode: 16, Type: 7,
April 2023 - Complaint: 1, Disposition: 9, Time: 36, Mode: 5, Type: 2, and
May 2023: Disposition: 13, Time: 36, Mode: 4, Type: 2.

None of the crossed off entries were dated and initialed per facility policy, 6 entries were obliterated by the use of white out and 10 entries were scribbled through making the original notation unreadable.

In an interview with ED Director C at 9:30 AM on 5/31/2023 ED Director stated, "We've had a few new people in the ED and I am aware that they are not keeping the log correctly. I continue to work with them and agree with what you identified with the use of white out and crossing off errors. It is not acceptable practice."