HospitalInspections.org

Based on interview and a review of facility documentation, the facility failed to ensure the maintenance of an accurate central log on each individual who comes to the emergency department seeking assistance for 1 of 21 sampled Emergency Department patients (#1).

Findings:

EMERGENCY DEPARTMENT LOG

A review of the Emergency Department log for 8/10/21 did not reveal the name of the patient as described in documentation below.

HOSPITAL DOCUMENTATION

A hospital investigation document of 8/13/21, written by the Risk Manager, read, "Per ED (Emergency Department) RN (Registered Nurse): LEO (Law Enforcement Officer) brought in a pt (patient) as a Baker Act. I gave the LEO a heads up.... he was more than welcomed but there will be a delayed report. LEO spoke with his Lt. (Lieutenant) and he asked to talk to me. I spoke with Lt....from....PD (police department) and the first thing he said was that I was refusing to take the pt. I explained to him that I never refused and that I only let the officer know that it would take a while to accept the patient due to bed availability..... Lt...told me 'I'll tell my officer to take the patient somewhere else'."

POLICIES

A review of hospital policy did not reveal anything which addressed situations involving the presentation of anonymous patients who leave abruptly after presentation and before the time in which staff can get to them for a proper registration.

INTERVIEWS

On 9/03/21 at approximately 10:53 AM, RN A stated that he had spoken to the Lieutenant on the telephone, after the law enforcement officer had himself spoken to him. He confirmed that the Lieutenant started off by accusing him of a refusal to accept the patient. He clarified to the Lieutenant that they were not refusing the patient and they will indeed accept the patient. He told him that it would take a little time to get a room available. He confirmed that the patient was taken away despite these clarifications. He stated that after the departure, he did not initiate any steps to log the patient in the computer system as an anonymous patient to document the presentation.

At 11:50 AM on 9/03/21, the Director of Emergency Services stated that a nurse cannot automatically enter anything in a record regarding a presenting patient until Patient Access has registered them with a name, date of birth and chief complaint. She stated that if such information is not available, the registratirar can create an anonymous account. She stated that at the time of the incident, there was no process in place to require a nurse or other receiving staff member to initiate steps for entering the anonymous status of presenting patients who have indicated a need for care but have departed after presentation and prior to the collection of their demographic information.

A patient had presented to the Emergency Department and quickly departed. There was no documentation in the Emergency Department log which recorded the presentation of the patient.

During an interview of the Risk Manager on 9/03/21 at 12:18 PM, she confirmed the finding.