HospitalInspections.org

Based on review of documents and staff interviews, it was determined the facility does not maintain a central log for all patients that presented to the facility for emergency care.

Findings include:

The facility was cited on 7/6/11during an EMTALA survey for noncompliance with maintaining a central log as required. The facility in its Plan of Correction dated 2/14/12 stated " Laboring patients that are seeking care in the Labor and Delivery unit (L&D) but entering the hospital through the Emergency Department will be registered and seen by an RN who will enter the patients ' information into ConnectCare. The centralized log is maintained electronically through the ConnectCare system. The centralized log references patients that present to L& D."

During a follow-up visit to determine compliance with this citation, the log for the " ConnectCare system" for 4/2/12 through 4/22/12 was reviewed on 2/24/12 with the GE Affinity log for OB patients from 2/20/12 to 4/24/12. It was determined that some OB patients bypass the ED and are directly admitted to the hospital via the L&D unit and they are not documented in the central log.

During staff interviews conducted on 4/24/12 at 12:10 PM, Staff #7 stated some OB patients are pre-registered at home and the registration forms are mailed or sent to the facility by those patients. When these patients are in labor, they contact their physicians ' who instructs them to go to the L&D unit for admission.

The administrative staff was repeatedly asked during the survey which ended on 4/26/12 to provide a central log. Staff #s 1, #2, #5 and# 6 were unable to provide a central log that included patients that presented to the ED as well as patients in labor that bypass the ED and are directed to the L&D unit.

Staff #1 provided a written statement on 4/26/12 which stated " Every patient that enters the ED is registered and placed in the ConnectCare electronic log. Every patient that enters the hospital is entered in Affinity which is an electronic system which does not interface with ConnectCare. As we move forward, the entire hospital will be on the same EMR (ConnectCare)."
THIS IS A REPEAT CITATION.

Based on medical record review, review of the EMTALA policy and staff interviews, it was determined the facility failed to document what aspects of the medical records, if any, was sent with patients when they were transferred to other facilities. This was found in 5 of 5 medical records of patients that had been transferred from the emergency department (ED). This was found in medical records #s 8, 20, 21, 25 and 26.

Findings include:

On 7/6/11 the facility was cited for lack of evidence regarding medical records sent to the receiving hospitals. In its Plan of Correction dated 2/14/12, the facility stated " Education regarding the EMTALA law and regulations was presented to the ED staff by the ED Director of Nursing in July and August 2011. Staff was educated again as to the required and appropriate information and documentation that must accompany a patient who is transferred."

1. A review of medical record #20 revealed this seventeen year old patient presented to the ED on 2/1/12 with pain and swelling to an injected needle site on her left forearm. This was attributed to illicit drug use. The patient was alert and oriented and her vital signs were within normal limits. Work-up included blood tests and an EKG were done. Vancomycin was given intravenously while the patient was in the ED. The patient was transferred to another facility for treatment of her swollen hand. There was no documented evidence that a copy of the medical record was sent with the patient to the receiving hospital.


2. MR #21 is a forty eight year old patient who presented to the ED on 2/1/12 because he was "very depressed and had upset his family." The patient felt that he was on the wrong medication. The patient also reported he was hearing voices to hurt himself. The patient's medical history was significant for Schizo-affective Disorder, Hypertension and Hyperlipidemia. The patient's mood was anxious, fearful, mildly guarded and mildly irritable. The patient's conduct was vigilant and suspicious and he was mildly-moderately paranoid.

The patient was given Haldol 5mg and Lorazepam 2mg by mouth in the ED. He was diagnosed with Schizo-affective Disorder, Chronic Mental Illness and Hypercholesterolemia. The patient was medically cleared for admission and a 2PC admission was done. The patient was transferred to another acute care facility but there was no evidence that a copy of the patient ' s medical record was sent with him to the receiving hospital. This is significant since the patient had co-morbidities and had received 2 medications while in the ED.

3. Similar findings were noted in MR #s 8, #25 and #26.

4. These findings were confirmed with Staff #1 on 4/26/12 at approximately 12:30 PM.

5. A review of the facility's "Transfer Policy (EMTALA)" effective 3/97 states, "staff must forward completed transfer forms including the Transfer Certification and copies of pertinent medical records, including lab results with the patient. The staff is then to note these documents were sent in the patient's medical record."

THIS IS A REPEAT CITATION.