HospitalInspections.org

Based on review of facility documentation and staff interviews (EMP), it was determined that the facility failed to maintain a central log on all patients who present to the Emergency Department.
Findings include:
Review of the facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated July 11, 2014, revealed, "...Each hospital facility shall maintain a central log in the Emergency Department identifying each individual that seeks emergency medical treatment at that facility, and indicate whether they refused treatment, or whether they were transferred, admitted , or discharged ... "
Review of the facility Emergency Department Procedure Manual "Quick Registration" dated 2013, revealed, "...Patient presents to front entrance desk as a walk in...Quick Registration employee obtains info to complete ERQ3 function...Patient completed NCR (...Emergency Department Patient Information Form)..."
1) Review of the facility Emergency Department central log, for the period of March 1, 2014, through August 26, 2014, revealed no documentation of patients who completed the Emergency Department Patient Information Form and then left before being seen for a medical screening examination (MSE).
2) During an interview on August 25, 2014, at 9:30 AM, EMP2 was asked about specific duties in the Emergency Department. EMP2 stated, " ...I register the patient as quickly as possible...quick reg (registration)...patient fills form out (Emergency Department Patient Information Form) and we enter the information." When asked about the completed form of a patient who decides to leave without being seen for a MSE, EMP2 stated, "I put it in a box under the desk ...you can't really register them." During the interview EMP2 also confirmed that no entry is made in the central log when a patient decides to leave without being seen for a MSE.
3) During an interview on August 26, 2014, at 10:15 AM, EMP3 confirmed that the central log was not maintained for patients who completed the patient information form and then left without a MSE. EMP3 revealed, "No....we do not enter the information into the computer (central log).

Based on review of facility documentation and employee interviews (EMP), it was determined that the facility failed to provide an appropriate screening examination for one of 10 medical records reviewed (MR1).
Findings include:
Review of the facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated July 11, 2014, revealed "...If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person."
1) Review of MR1 included the following documentation dated August 19, 2014, "Chief Complaint: si (suicide ideation) Focused Assessment of Complaint: reports suicidal thoughts, denies attempt, denies drug or alcohol use. ED Screening - There is no ED screening/Fall Risk/HIH Stroke information to display. Focused Physical Assessment: (All areas are blank with no documentation)."
2) Interview with EMP1 on August 25, 2014, at 11:00 AM, revealed, "[MR1] was given a bus ticket and wasn't seen by a physician."

Based on review of facility documentation, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure a patient's medical screening examination and/or treatment was not delayed for one of 35 medical records reviewed (MR13).

Findings include:

Review of the facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated July 11, 2014, revealed "...If an individual seeking emergency medical care comes to the hospital's Dedicated Emergency Department, physicians or other Qualified Medical Person (QMP) shall offer a Medical Screening Exam to such person."

Review of facility procedure "Direct Admits From DEM To Obstetrical, L&D Suite" dated February 2014, revealed "All pregnant patients presenting to the Department of Emergency Medicine (DEM) who are 16 weeks or greater gestation with complaints which are suspicious for labor or threatened abortion shall be directly transported to the L&D suite for primary evaluation. ... 1. All OB (obstetrical) patients who are full term or near full term who present to the DEM in obvious labor will be transported directly to the OB unit. 2. All other patients presenting to the DEM will be first evaluated by the Triage RN (if presenting to Admission/Triage) or Charge RN (if arrival via medic unit on stretcher). The decision to directly transport to the L&D suite will be made after the initial assessment."

1) Review of MR13 revealed that on August 7, 2014 patient was transported by ambulance to the facility ' s emergency department (ED) after a 911 call was received with reports of shortness of breath and chest pain. The documentation also indicated that the patient entered the facility through the ED, but taken directly to the L&D Suite.

2) Review of MR13 also revealed that the patient was an 18-year-old female at 29 weeks of gestation. There was no documentation to indicate that the patient had complaints which were suspicious for labor or threatening abortion or that the patient was in active labor. An Ob-Gyn Triage note confirmed that there were no reports of contractions or abdominal pain and that the patient had complaints of shortness of breath and chest pain. Additionally, there was no documentation in the medical record to indicate that the patient who presented to the DEM was first evaluated by the Triage RN or charge RN, as per facility policy.

Interview with EMP10 on August 26, 2014, at 10:00 AM, revealed, " When a pregnant patient comes in to the ED for chest pain, they are seen in the ED, and if obstetrics is needed they are evaluated by Obstetrics. "

Based on a review of facility policy and medical records (MR) and staff interviews (EMP), it was determined that the facility failed follow policy and failed to ensure appropriate documentation for transferring from the Emergency Department for one of six medical records reviewed (MR28).

Findings include:

Review of the facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA)" dated July 11, 2014, revealed "...It is the policy of UPMC to comply with all applicable laws and regulations relating to the provision of emergency of emergency services, including the Emergency Medical Treatment and Active Labor Act (EMTALA), ....The physician or QMP [qualified medical personnel] must certify in writing on a certification form or in the medical record. The certificate or documentation will state the reason for transfer, patient condition, benefit/risks of transfer, receiving hospital, mode of transportation, and patient consent."

1) Review of MR28 revealed ERC Assessment Data, dated April 5, 2014. Documented on page 10 (under the Transfer of Patient to Other Facility section) is "Clarion" (for facility) and "4/5/14" (for date). No other information was documented in that section. The ERC Assessment Data also indicated that additional information could be found in the "patient transfer to outside facility summary document." The referenced document was not located in MR28. The record failed to include the certificate or documentation regarding the reason for transfer, patient condition, benefit/risks of transfer, receiving hospital, mode of transportation, and patient consent, as per facility policy.

2) During an interview on August 26, 2014, at approximately 10:00 AM EMP9 stated, "There is no transfer documentation in the record."

3) Interview with EMP 1 on August 26, 2014, at approximately 12:45 PM confirmed that there was no transfer documentation in MR28.