HospitalInspections.org

Based on record reviews and interviews, the hospital failed to:
1) develop a system and policy for maintaining a computerized Emergency Department (ED) central log when the hospital converted from a paper log to a computerized system. This resulted in gaps in the central ED log as evidenced in failure to have the triage acuity level, the reason for the visit, the name of the ED physician performing the emergency medical screening exam, and/or the disposition on 09/15/13, 09/16/13, 09/17/13, 09/18/13, 10/14/13, and 11/03/13 for 23 random patients (R1 - R23) and
2) Ensure the central ED log was accurately maintained as evidenced by having the incorrect disposition on the log for 2 of 21 patients' ED records reviewed (#4, #16).
Findings:

1) Develop a system and policy for maintaining a computerized Emergency Department (ED) central log when the hospital converted from a paper log to a computerized system. This resulted in gaps in the central ED log as evidenced in failure to have the triage acuity level, the reason for the visit, the name of the ED physician performing the emergency medical screening exam, and/or the disposition on 09/16/13, 09/17/13, 09/18/13, and 10/14/13:
Review of the hospital's policy titled "Emergency Department Register (Log)", revised 06/11 and presented as the current policy by S1Administrator, revealed that the ED log is maintained listing all patients presenting for care to the ED in consecutive order of arrival. Further review revealed that all spaces are to be completed by indicating the following information: insurance, age, arrival time, triage time, means of admission, chief complaint, ED physician, family physician, triage acuity, lab, x-ray, respiratory therapy, EKG (electrocardiogram), physician exam time, treatment provided, diagnosis, RN (registered nurse) signature, transport personnel notified of contagious condition, time of discharge, means of departure, disposition. Further review revealed that no blank lines will be left in the ED log.

Review of the copies of the computerized central ED log for May 2013 through November 12, 2013 presented by S2Clinical Nurse Manager revealed the data maintained on the log included the patient's name, the medical record number, the patient's age and sex, the check-in and check-out date and time, the acuity level at triage, the diagnosis, the reason for the visit, the name of the ED physician and nurse, the name of the admitting physician, and the discharge disposition.

Review of the central ED logs for September 2013, October 2013, and November 1st through November 12th, 2013 revealed the following:
09/15/13 - Patient R4 with no documented evidence of the disposition at discharge;
09/16/13 - Patient R5 with no documented evidence of the disposition at discharge;
09/16/13 - Patient R6 with no documented evidence of the disposition at discharge;
09/16/13 - Patient R7 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/16/13 - Patient R8 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/16/13 - Patient R9 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/16/13 - Patient R10 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/16/13 - Patient R11 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/16/13 - Patient R12 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/17/13 - Patient R13 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/17/13 - Patient R14 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/17/13 - Patient R15 with no documented evidence of the triage acuity level;
09/17/13 - Patient R16 with no documented evidence of the name of the ED physician;
09/17/13 - Patient R17 with no documented evidence of the triage acuity level;
09/17/13 - Patient R18 with no documented evidence of the triage acuity level;
09/17/13 - Patient R19 with no documented evidence of the triage acuity level;
09/18/13 - Patient R20 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/18/13 - Patient R21 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/18/13 - Patient R22 with no documented evidence of the triage acuity level, the reason for the visit, and the diagnosis;
09/18/13 - Patient R23 with no documented evidence of the triage acuity level;
10/14/13 - Patient R1 with no documented evidence of the triage acuity level, the diagnosis, and the ED physician name;
11/03/13 - Patient R2 with no documented evidence of the triage acuity level;
11/03/13 - Patient R3 with no documented evidence of the triage acuity level.

In a face-to-face interview on 11/13/13 at 11:25 a.m., S1Administrator indicated that the ED log policy was an old policy that was used when the ED log was written. She further indicated that she did not discover that the hospital had not revised the policy to reflect the procedure used when the hospital instituted electronic medical records and a computerized ED log until the policy was requested during the survey.

In a face-to-face interview on 11/13/13 at 1:10 p.m., S3EMR (electronic medical record) Specialist indicated that gaps in the ED log may be due to times when the computer system was down. She further indicated that when the computer system comes back up, the ED log is not updated. S3EMR Specialist indicated that the hospital did not have a system in place for maintaining the ED log when the computer system was down. She further indicated that when the physician's or nurse's name was not documented on the log, it was probably due to the nurse or physician not assigning themselves to the patient in the computer system.

2) Ensure the central ED log was accurately maintained:
Patient #4
Review of the central ED log revealed that Patient #4 was a 20 year old male who presented to the ED on 11/04/13 at 1:08 p.m. with the chief complaint of suicidal ideation. Further review revealed his disposition was discharged to home with self-care.

Review of Patient #4's ED record revealed he was PEC'd (physician emergency certificate) on 11/04/13 at 2:30 p.m. due to being suicidal, gravely disabled, and a danger to self. He was CEC'd (coroner's emergency certificate) on 11/04/13 at 4:00 p.m. due to feeling like shooting himself in the head with a pistol, being suicidal, gravely disabled, and a danger to self. Further review revealed Patient #4 was transferred to Hospital B on 11/05/13 at 1:23 a.m.

In a face-to-face interview on 11/13/13 at 1:35 p.m., S6ED RN indicated there's a place to select from a list of options for disposition at the end of discharging a patient in the computer, and she can't explain why the ED log shows that Patient #4 was discharged home when he actually was transferred to an inpatient psychiatric facility.

Patient #16
Review of the central ED log revealed that Patient #16 was a 69 year old male who presented to the ED on 10/08/13 at 12:09 p.m. with a chief complaint of weakness or fatigue and malaise, and his disposition was that he left against medical advice (AMA). Review of his ED triage note revealed his chief complaint was weakness, abdominal pain, and shortness of breath.

Review of Patient #16's ED record revealed S14ED Physician documented a physical examination, review of systems, and medically cleared him for discharge to home on 10/08/13. He was discharged on 10/08/13 at 2:54 p.m. and left without receiving discharge instructions.

In a face-to-face interview on 11/13/13 at 11:10 a.m., S2Clinical Nurse Manager indicated that Patient #16's ED record had no documentation that revealed he left AMA. She further indicated that a patient leaving without discharge instructions doesn't mean the patient left AMA.

In a face-to-face interview on 11/13/13 at 11:15 a.m., S3EMR Specialist indicated that the nurse had requested that she (S3EMR Specialist) change Patient #16's disposition in the computer from AMA to discharged home. She further indicated that she changed the disposition in the computer system, but her action did not change the disposition on the ED log.