HospitalInspections.org

Based upon document review and interview, the facility did not comply with all of the provisions for maintaining a central log and conducting a medical screening exam. Please reference findings under Tag A2405 and A2406.

Based on document review and interview, the facility failed to ensure that all individuals presenting to the Emergency Department (ED) are entered into the central log for 1 of 26 patients (Patient #1). This failure could result in a patient not receiving a medical screening exam.

Findings include:

Review of ENH -Nursing TRIAGE: (Emergency Severity Index) ESI Policy revised 10/10/15 revealed triage is the process by which the RN prioritizes patients (according to severity of illness or injury and level of resources needed by the patient) upon arrival to the Emergency Department (ED). All patients will be directed to the triage area on arrival to the ED, except emergency cases which will be taken immediately to a treatment area.

Interview with Staff G on 3/1/16 at 10:00am revealed that patients presenting to the ED are entered into the ED central log. The patient information obtained is then transmitted to the tracker board located in the ED for viewing by the clinical staff, following which the RN triages the patient.

Review of the ED central log dated 2/13/16 to 2/15/16 revealed Patient #1 was not entered into the log.

Interview with Staff C on 3/1/16 at 9:00am revealed the patient presented to the ED on 2/14/16 sometime after midnight requesting to be seen. The patient was noted to be pregnant with complaints of bleeding. The registration clerk contacted the maternity unit, but did not enter the patient into the central log. After questions related to who the patient's physician was and how much bleeding the patient had were relayed between the maternity nurse, registration clerk and patient, the patient questioned if she should have gone on to the hospital her physician was at and was told that it was her choice. The patient left and presented to the other hospital on 2/14/16 at 2:09am.

Interview with Staff B on 3/1/16 verified the above finding.

Based upon interview and document review, the hospital did not provide a medical screening examination for 1 of 26 patients who presented to the Emergency Department (ED) (Patient #1). A lack of a medical screening exam could result in an emergency medical condition not being identified and treated.

Findings include:

Review of the facility's Emergency Medical Treatment and Active Labor Act (EMTALA) Policy, last reviewed March 2015 revealed that any patient presenting to the hospital and requesting treatment for a medical condition, will receive a medical screening exam by a physician to determine if an emergency medical condition exists.

Interview with Staff C on 3/1/16 at 9:00am revealed the patient presented to the ED on 2/14/16 sometime after midnight requesting to be seen. The patient was noted to be pregnant with complaints of bleeding. The registration clerk contacted the maternity unit, but did not enter the patient into the central log or generate a medical record. After questions related to who the patient's physician was and how much bleeding the patient had were relayed between the maternity nurse, registration clerk and patient, the patient questioned if she should have gone on to the hospital her physician was at and was told that it was her choice. The patient left without a medical screening exam and presented to the other hospital on 2/14/16 at 2:09am, where she was evaluated and treated.

Medical record review revealed no evidence that a medical record was generated or that a medical screening exam was performed on 2/14/16 for Patient #1.

This finding was verified with Staff B on 3/1/16.