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Tag No.: C2400
Based on observation, document review, and staff interview it was determined the facility failed to comply with §489.24 by not maintaining a complete log on each individual who comes to the Emergency Department (see Tag C 2405). This failure has the potential to negatively affect all patients presenting to the Emergency Department for care.
Tag No.: C2405
Based on observation, document review, and staff interview it was determined the facility failed to maintain a complete log on each individual who comes to the emergency department in one (1) out of twenty (20) patients (patient #1). This failure has the potential to negatively affect all patients presenting to the Emergency Department (ED) for care.
Findings:
1. A video review was conducted of 11/24/19 from 11:46 a.m. through 12:25 p.m. The video revealed a patient, confirmed as patient #1, and deputy entering the ED ambulance entrance doors at 11:46 a.m. The deputy left with patient #1 following behind at 12:25 p.m.
2. A review of the ED log for 11/24/19 from 11:45 a.m. through 12:25 p.m. revealed there was no entry for patient #1.
3. An interview was conducted with The Nurse Manager of the ED on 12/16/19 at 12:00 p.m. She confirmed there was no log entry, no triage, and no medical screening of patient #1.
Tag No.: C2406
Based on observation, document review and staff interview, it was determined the facility failed to provide an appropriate medical screening examination in one (1) out of twenty (20) patients (patient #1). This failure has the potential to negatively affect all patients presenting to the Emergency Department (ED) for care.
Findings:
1. A video review was conducted of 11/24/19 from 11:46 a.m. through 12:25 p.m. The video reveals a patient, confirmed as patient #1, and deputy entering the ED ambulance entrance doors at 11:46 a.m. The deputy left with patient #1 following behind at 12:25 p.m.
2. A review of the ED log for 11/24/19 from 11:45 a.m. through 12:25 p.m. revealed there was no entry for patient #1.
3. A statement to the facility written by the deputy who escorted patient #1 to the ED, not dated, was reviewed. It stated in part, "The physician asked me if this is (patient #1) normal state of mind, and I stated yes, this is the second time I've dealt with him and his mental status has been the same both times. The physician stated to me he was not going to see (patient #1) because there was nothing he could 'work him up for'. I then stated to the physician that given his mental status and not being able to make contact with the family I brought him here to be checked. The physician again stated he wasn't going to do anything."
4. A review was conducted of policy titled "Transfer of Patients-EMTALA," last revised date 03/2019. The policy states in part under "II. Policy: Any person who comes to GMH (Grant Memorial Hospital) requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening examination performed by a qualified provider to determine whether an emergency medical condition exists."
5. An interview was conducted with the Nurse Manager of the ED on 12/16/19 at 12:00 p.m. She confirmed there was no log entry, no triage, and no medical screening of patient #1.