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Based on interview and record review, Hospital A failed to enforce its policy to ensure compliance with 489.24 (a) (1) (i) and 489.20 (r) (3). The ED (emergency department) did not provide a medical screening exam and any necessary treatment to Patient #1 on 01/02/17. Patient #1 presented to the ED with a complaint of a burn to her abdomen. The patient was screened and treated at Hospital C on the same day.

Cross refer to A2405 and A2406.

Based on interview and record review the hospital failed to maintain an ED (emergency department) central log on 1 of 20 (Patient #1) patients reviewed who presented to the emergency department seeking treatment.

Findings included:

During a review of Hospital A's ED Central logs on the morning of 02/07/17, the log dated 01/02/17 didn't reflect an entry for Patient #1.

During an interview on 02/07/17 at 11:49 AM, Personnel #1 was asked by the surveyor if Patient #1 had been seen in the hospital. At 12:10 PM Personnel #1 gave the surveyor the ED Arrival Information form for Patient #1 and said that was all of the documentation that was available for the patient. She confirmed Patient #1 wasn't listed on the ED Central log dated 01/02/17.

A review on 02/07/17 of Patient #1's ED Arrival Information form reflected Patient #1 arrived in the ED on 01/02/17 at 12:14 PM.

During an interview on 02/07/17 at 12:15 PM with Personnel #2, she said patients filled out a paper registration form upon arrival in the ED. The information was then entered into the patient information system called Epic. Personnel #2 didn't know why Patient #1 wasn't listed on the ED Central log, but she should have been.

During an interview on 02/07/17 at 12:21 PM with Personnel #3, she said she remembered Patient #1. She came into the ED and was crying. She didn't have a shirt on with her jacket and she could see the patient's abdominal wound. Personnel #3 said "it looked pretty bad." Personnel #3 called the triage nurse and told her about Patient #1's condition. She didn't remember who the nurse was, but Patient #1 was taken back to a room by a nurse or an ED technician (tech). Patient #1 should have been on the ED Central log.

During an interview on 02/07/17 at 2:55 PM with Personnel #4, she said she remembered Patient #1. She was in room #21 in the Fast Track unit of the ED. Personnel #4 said she always entered patient information into the system and didn't understand why there wasn't a record of the patient's visit.

During a telephone interview with Personnel #7 on 02/08/17 at 12:42 PM, she confirmed Patient #1 had documentation showing she had arrived at the ED and registered, but there was no other documentation found.

Based on interview and record review the hospital failed to ensure 1 of 20 (Patient #1) patients reviewed had a medical screening exam.

Findings included:

During a review of Hospital A's ED Central logs on the morning of 02/07/17, the log dated 01/02/17 didn't reflect an entry for Patient #1.

During an interview on 02/07/17 at 11:49 AM, Personnel #1 was asked by the surveyor if Patient #1 had been treated in the ED. At 12:10 PM, Personnel #1 gave the surveyor the ED Arrival Information sheet for Patient #1 and said that was all of the documentation that was available for the patient. Personnel #1 confirmed Patient #1 wasn't listed on the ED Central log and didn't have a medical record.

A review on 02/07/17 of Patient #1's ED Arrival Information sheet reflected Patient #1 was an 8 year-old female who arrived in Hospital A's ED on 01/02/17 at 12:14 PM with a complaint of an abdominal burn.

During an interview on 02/07/17 at 12:15 PM with Personnel #2, she said patients filled out a paper registration form upon arrival in the ED. The information was then entered into the patient information system called Epic. Personnel #2 didn't know why Patient #1 didn't have a medical record but that she should have one.

During an interview on 02/07/17 at 12:21 PM with Personnel #3, she said she remembered Patient #1. She came into the ED and was crying. She didn't have a shirt on with her jacket and she could see the patient's abdominal wound. Personnel #3 said "it looked pretty bad." Personnel #3 called the triage nurse and told her about Patient #1's condition. She didn't remember who the nurse was, but Patient #1 was taken back to a room by a nurse or an ED technician (tech). Patient #1 "went back definitely [to an ED treatment room]."

During an interview on 02/07/17 at 2:55 PM with Personnel #4, she said she remembered Patient #1. She was in room #21 in the Fast Track unit of the ED. She thought Personnel #5 and #6 were also in the room. Personnel #4 examined Patient #1 at the same time as Personnel #6. The medication silvadene cream was applied to Patient #1's abdominal wound, but Personnel #4 said she didn't apply it. She remembered there was talk about maybe putting wet towels on her wound, but she didn't remember if they were placed on the wound or not. Personnel #4 said she always entered patient information into the system and didn't understand why there wasn't a record of the patient's visit.

During an interview on 02/07/17 at approximately 3:30 PM with Personnel #5, she said she didn't remember Patient #1.

During a telephone interview on 02/08/17 at 8:58 AM, Personnel #6 said she didn't remember taking care of Patient #1. That day she took care of a burn on a 2 year old but not on Patient #1. Personnel #6 said she wasn't sure what day it was, but she remembered hearing "chatter" outside of a treatment room. Someone was saying that the mother of a child with a burn was told to go to Hospital B because "we were too busy." Personnel #6 said she walked out to the registration area to see if the patient was still there. She asked where the patient was and was told she had left. "Nursing or medicine never saw that child to my knowledge."

During a telephone interview with Personnel #7 on 02/08/17 at 12:42 PM, she confirmed Patient #1 didn't have a medical record, but did have documentation showing she had arrived at the ED and registered.

During a telephone interview with Personnel #8 on 02/08/17 at 12:58 PM, she said she was working in the ED at the time of Patient #1's arrival in the ED. She said she had no memory of seeing or treating the patient. All patients with burns would have a physician lay hands on them even if there was involvement by a mid-level practitioner.