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Based on medical record review, policy review, ED log review, CFR review, and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A - 2405 as it relates to the hospital's failure to maintain a central log on all individuals who came to the emergency department seeking emergency medical treatment for 1 of 20 (Patient #11) patients who's records were reviewed.

Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the hospital seeking emergency care.

Based on medical record review, policy review, ED log review, CFR review, and staff interview, it was determined the facility failed to maintain a central log on all individuals who came to the hospital seeking emergency medical treatment. This resulted in 1 of 20 patients (Patient #11) not being documented on centralized ED log. This had the potential to interfere with the hospital's ability to track all emergency patients and to assess whether patients received appropriate screenings, stabilizations, and transfers. Findings include:

According to 42 CFR § 489.24 Special responsibilities of Medicare hospitals in emergency cases, "Comes to the emergency department means, with respect to an individual who is not a patient (as defined in this section), the individual ... (2) Has presented on hospital property, as defined in this section, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf."

A facility policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) and Transfers in to or Out of St. Luke's Health System Facilities," revised 5/17/24, was reviewed. The policy stated, "EMTALA applies when an individual comes to the ED. This means that the individual meets any one of the following four conditions: ... Presents On-Campus: The individual presents On-Campus (other than a Dedicated ED), including Labor & Delivery, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf." The policy also stated, "The following signs shall be posted, and records maintained: ... D. Central Log of Emergency Care: Maintain in the ED and L&D a central log of individuals who come to the ED or L&D seeking treatment and indicate whether these individuals: (1) refused treatment, (2) were denied treatment, or (3) were admitted, transferred or discharged. This central log may be a report from the electronic health record." This policy was not followed. An example includes:

Patient #11 was a 13 year old pregnant female who presented to the Labor & Delivery unit on 8/07/24 with contractions and possible rupture of membranes. She presented to the Labor & Delivery unit to assess for possible labor. Labor was ruled out, and Patient #11 was discharged and told to follow up with obstetrics.

Patient #11's ED visit encounter record was reviewed as part of her electronic medical record. There were no emergency visits documented in the visit encounter record for Patient #11 in 2024.

ED logs were requested upon entrance of the survey on 11/12/24 at 11:00 AM. The ED logs were reviewed, but Patient #11's 8/07/24 visit was not documented in the ED logs originally provided.

Patient #11's medical record for the 8/07/24 visit was reviewed with the Quality Manager and Inpatient Nurse Manager on 11/13/24 at 1:39 PM. The Quality Manager confirmed the 8/07/24 visit was an unscheduled ED visit. The surveyor reviewed that the 8/07/24 visit was not on any of the central logs previously provided. The Quality Manager stated the central log previously provided included all obstetric visits for the hospital. When asked about a walk in log for patients presenting to Labor & Delivery seeking emergency treatment, The Inpatient Nurse Manager said she was not sure about a log for those patients. It was unclear why the central log did not include Patient #11's Labor & Delivery walk in visit.

After reviewing Patient #11's 8/07/24 visit with the Quality Manager, a log was provided which showed the 8/07/24 visit. This log was provided the afternoon of 11/13/24, after the unscheduled visit was reviewed with the Quality Manager and noted that Patient #11's 8/07/24 visit was not on the central logs previously provided. The log was originally requested on 11/12/24 at 11:00 AM. It was unclear why Patient #11's 8/07/24 visit was not on any of the central logs originally provided.

The hospital failed to maintain a central log on all individuals who came to the hospital seeking emergency medical treatment.