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SAINT CLARE'S HOSPITAL
EMERGENCY ROOM LOG
Tag No.: A2405
Based on staff interview and review of facility documents, it was determined the facility failed to ensure the central log, of patients presenting in the emergency department (ED), was maintained.
Findings include:
On 10/23/24 at 10:27 AM, the ED central logs for the dates of 9/21/24, 9/22/24, 9/23/24, 9/24/24, and 9/25/24, were requested for review. Upon review, seven patients did not have an ED disposition.
Facility policy, titled, "EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act," revised 9/18/24, stated, "... Guidelines: ... 2. Central Log: Each department of the hospital that provides medical screening examination shall maintain a central log recording the following: ...m. Disposition of patient including refusal of treatments, transfers, admitted, stabilized and transferred or discharged ..."
On 10/24/24 at 10:27 AM, Staff (S) 1 confirmed the dispositions were missing and a review of the facility policy was shared with S1 regarding the items required per policy, on the ED central log. S1 stated that the ED Director would be the person to monitor the central log for completeness. S1 further stated the facility was in a transition period with regards to an ED director. The prior ED director left his/her position in July of 2024 and the new ED director, S7, started at the facility in September of 2024.