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Based on interview, record review, and observations, the facility failed to maintain a central log for each individual who came to the emergency department for 1 out of 20 (Patient #1) patients. Patient #1 presented to the hospital on 1/9/2024 and was not listed on the hospital's central log.

The findings included:

Interviews

In interviews with Staff #5, Patient Access Manager, and Staff #6, Patient Access Specialist, conducted on the afternoon of 2/27/2024, both staff #5 and staff #6 confirmed individuals are not documented on a central log if they present seeking examination or treatment if they do not complete a registration form. Staff #6 indicated she did not recall an incident with Patient #1 however she was never trained nor aware of the EMTALA policy which requires all individuals to be documented, even if they leave without being seen.

In an interview conducted on 2/27/2024 at 10:30 AM, Staff #3, Quality Manager, confirmed patients who do not complete registration are not listed on a Central Log.

Record Review

The facility policy titled, "EMTALA," updated on 9/2023 states,
Central Log
1. The hospital must maintain a central log of individuals who come to the emergency room seeking an examination and or/treatment for an emergency medical condition (including psychiatric conditions.) All individuals who present for an examination or treatment in the emergency department must be entered into the Central Log, even if they leave prior to triage or MSE.

2. The log shall include the individual's name, date, time, chief complaint/diagnosis, and their disposition, which should indicate if the patient was:
a. Admitted
b. Discharged
c. Transferred
d. Refused MSE or stabilizing treatment
e. Was refused treatment
f. Left without being seen (LWBS/LWOBS)
g. Eloped or Left Against medical advice

3. If a presenting individual left prior to completing the initial registration, an ED staff member should document, if the individual's first and last name and DOB is not known, a description of the individual into the designated event/incident reporting system.


A review of the facility's central log for date 1/9/2024 was conducted on 2/26/2024 at 10:50 AM. Although Patient #1 presenting to the ED, Patient # 1 could not be found on a central log or registration log.


Observations

A review of video surveillance of 1/9/2024 was conducted on 2/27/2024 at 11:45 am with Staff #3. The video surveillance shows Patient #1 arriving from left side of the Emergency Room Department entrance doors. Patient #1 was accompanied by an unknown person. At 11:57 AM, Patient #1 walked in and was seen on the phone. Patient #1 does not approach the front desk. Staff #6 is seen sitting and waiting for patient to approach. At 11:59 AM Patient #1 approaches and is given a clipboard and paperwork. Staff #6 is seen grabbing an additional document from a folder on the wall. Patient #1 and Staff #6 are seen talking. There is no audio to determine what the communication was. After the exchange, Patient #1 is seen handing the clipboard back to the reception and walks out of the doors. Video surveillance confirmed Patient #1 presented seeking examination or treatment