HospitalInspections.org

Based on policy review, video review, document review, medical record review, and interview, the hospital does not ensure that all patients who present to the emergency department are entered on the emergency department central log, specifically for Patient #1. The emergency department central log is required to track the care provided to each patient who presents to the hospital seeking care for an emergency medical condition.

Findings include:

Review of the policy "Triage," effective 02/2022 indicated that all patients presenting to the emergency department will be greeted by the registration clerk who will obtain the patients first/last name, date of birth, arrival time, and chief complaint. The registration clerk will notify the designated triage nurse that a patient has arrived, enter their information into electronic health record, and place the patient on the emergency department tracking board.

Review on 03/11/24 at 04:15 PM of video surveillance with Staff (M), Director of Healthcare Information Systems, revealed that on 02/19/24 at 06:10 PM, Patient #1 and their mother walked into the emergency department and was observed speaking with Staff (K), Patient Information Specialist (registration staff). At 06:13 PM, Staff (K), Patient Information Specialist, placed a band (identification bracelet per Staff M) on Patient #1's wrist. At 06:14 PM, Patient #1 and their mother walked into the waiting room. At 06:18 PM, Staff (L), and Staff (R), Registered Nurses were observed walking to the waiting room and spoke to Patient #1's mother. At 06:22 PM, Staff (L) and Staff (R) were observed walking back into the emergency department. At 06:23 PM, Staff (L) was observed bringing something out to the waiting room, giving it to Patient #1's mother (medical supplies), and walking back into the emergency department. At 06:25 PM, Patient #1 and their mother walked out of the facility.

Review of the document "Wyoming County Community Hospital Emergency Department Log," dated 02/19/24 revealed no evidence Patient #1 presented to the hospital's emergency department.

Medical record review on 03/11/24 revealed no evidence that a medical record was generated for Patient #1 on 02/19/24.

Interview on 03/11/24 at 11:30 AM with Staff (D), Director of Informatics and Nursing Education, confirmed that a medical record was not generated for Patient #1's presentation to the emergency department on 02/19/24.

Interview on 03/11/24 at 02:22 PM with Staff (H), Patient Information Specialist, recalled that Patient #1 came in with their mom, was registered, and went to the waiting room. The nurse went to the waiting room to talk to the mom and brought them supplies. Patient #1 left with the mother. They (registration staff) were then told by someone in the emergency department to cancel the account out as Patient #1 was not treated.

Interview on 03/11/24 at 03:05 PM with Staff (K), Patient Information Specialist recalled that Patient #1 came into the emergency department on 02/19/24 with their mother for treatment. Staff (K) registered the patient, placed the wrist band on Patient #1, called back to the triage nurse to make aware of the patient ' s arrival, and told Patient #1 ' s mother to wait in the waiting room for treatment. Staff (K) stated the triage nurse asked for details as to why they arrived for treatment. Two nurses went to the waiting room, spoke to Patient #1 ' s mother, and brought them supplies. Patient #1 and the mother left the facility. A nurse called Staff (K) and asked for the registration to be reversed and to cancel the account, which was completed by Staff (K).

Interview on 03/12/24 at 12:45 PM with Staff (O), Registration Supervisor and at 02:04 PM with Staff (B), Director of Nursing, verified that Patient #1 was not documented on the emergency department log for 02/19/24.