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SCHUYLER HOSPITAL
COMPLIANCE WITH 489.24
Tag No.: C2400
Based upon policy review, document review, and interview the facility did not comply with all the provisions for maintaining a central log. Please reference finding under 2405.
EMERGENCY ROOM LOG
Tag No.: C2405
Based on policy review, document review and interview the facility did not ensure all individuals presenting to the emergency department (ED) are entered into the patient log for 1 of 20 patients (Patient #1).
Findings include:
Review of policy "Transfer Policy", effective 02/01/97 revealed the central log is a log the hospital is required to maintain on each individual who comes to the emergency department seeking care and whether he or she refused treatment or were refused treatment, transferred, admitted and treated, stabilized and transferred or discharged.
Review on 09/29/20 of the Schuyler Hospital ED log dated 07/19/20 revealed no evidence Patient #1 was entered into the ED log.
Telephone interview on 09/29/2020 at 09:00 AM with Staff (P), NP-ED, revealed that she was the provider in the ED on 07/19/2020. She stated she does recall being asked by the ED Registration person to come out and speak to a father and his daughter. Staff P stated that she went out the ED waiting room and spoke to the father, who was requesting a "rape kit" (NYS Sexual Offense Evidence Collection (SOEC) kit) be done on his daughter. Staff (P) stated she talked with the father and informed him that the facility is fully capable of examining and collecting specimens for the SOEC, if Patient #1 consents to having it done. Staff (P) stated she informed the father that if Patient #1 consents to the exam/collection, then she can check in with the ED Admission clerk and be brought back to the ED for the exam and collection for the SOEC kit. Staff (P) stated that Patient #1 did not want to have the exam/collection done. Staff (P) further stated that she was never given a form for Patient #1 from the ED Admissions clerk, and does not believe Patient #1 checked into the ED.
Interview with Staff (A), RN Director of Clinical Operations on 09/29/20 at 01:45 PM verified the above findings.