HospitalInspections.org

Based on review of facility documents, and staff interview (EMP) it was determined the facility failed to document the disposition of a patient on the registration log for one patient (OTH1).

Findings include:

Review on June 20, 2024, of the facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated May 29, 2024, revealed "... II. Purpose This policy sets forth the system hospitals' requirements under EMTALA, including guidelines for providing the appropriate setting (department) for conducting medical screening for all individuals. ... IV. Definitions ... 2. Emergency Medical Condition is "a medical condition manifesting itself by acute symptoms of sufficient severity ... such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. .... V. Procedure 1. If an individual seeking emergency medical care, the hospital's Dedicated Emergency Departmental QMP shall...4. If the patient leaves before undergoing or completing a medical screening exam, the QMP or staff shall note this in the Emergency Department record or log. If the patient or their representative refuses treatment, the QMP or other staff shall note the type of treatment refused in the Emergency Department record or log and take reasonable steps to secure a written informed refusal by the patient or their representative. ... 13. Each hospital facility shall maintain a log in the Emergency Department identifying each individual who seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted, stabilized and transferred or discharged. These logs shall be retained for five (5) years.

Review on June 20, 2024 of the registration log for June 15, 2024 revealed OTH1 checked in to the Emergency Department (ED) at 0517 and checked out at 0533 with a diagnosis of left side testicle pain. OTH1 arrived walking. The discharge disposition was blank. OTH1 signed a consent for treatment on June 15, 2024 at 0519.

Interview on June 20, 2024 with EMP8 at approximately 1300 was conducted via a TEAMS meeting . EMP8 provided the following information: EMTALA training was completed yearly. EMP8 was responsible to disseminate EMTALA training to the facility's providers. Per EMP8, EMTALA means anyone presenting on hospital property (and defined as within 250 yards of the hospital) requesting evaluation is to receive a medical screening examination, and no one is turned away. EMP8 did recall OTH1 presented to the ED on June 15, 2024 around 4-5 AM, with left testicular pain. EMP8 was working at the time OTH1 presented to the ED. EMP8 revealed a discussion took place with OTH1 regarding options/plan for care. OTH1 could receive a medical screening exam (MSE) and if indicated provide for transportation to UPMC Williamsport via ambulance (again if indicated) where the patient could be provided an ultrasound. He noted ultrasound would not be available for approximately 1 hour at Lock Haven. EMP8 noted there would be a fee for the ED visit and transport via ambulance to UPMC Williamsport. The second option would be OTH1 and a family member could travel via their private automobile to UPMC Williamsport ED for examination and ultrasound. EMP8 stated they did speak with EMP16 at UPMC Williamsport apprising them of the possibility that the OTH1 and a family member would be presenting to their ED for care. EMP8 revealed OTH1 decided to travel via private auto to Williamsport for care. EMP8 noted this information was not charted anywhere. EMP8 had requested that when the patient left the documentation would note left without being seen (LWBS). This was not done. EMP8 revealed they wanted documentation as LWBS so the patient would not be charged for the presentation to Lock Haven ED. EMP8 revealed documentation is everything and this is what they failed to do.