HospitalInspections.org

Based on facility policy review, review of ER logs, medical record review, and interview, the facility failed to maintain an accurate central log for one patient (#11) of twenty-three patients reviewed.

The findings included:

Review of facility policy titled "Emergency Medical Treatment & Active Labor Act (EMTALA) Guidelines" revealed, "...Effective date: 1/14...purpose of this policy is to establish guidelines for EMTALA compliance...Central Log All patients presenting to the Emergency Department (ED) requesting evaluation and treatment will be logged in the ED log. The ED log will include the disposition of the patient and will indicate whether these individuals were: Refused Treatment Denied Treatment Treated Admitted Condition (Stabilized) Transferred Discharged...All patients presenting for obstetrical conditions and receiving a medical screening exam in the ED Department will be logged in the ED log..."

Review of an ER log entry dated February 27, 2014, revealed, "...(Patient #11)...Seen By (Medical Doctor- M.D. #6)..." Continued review revealed no documentation regarding disposition of patient #11.

Medical record review revealed Patient #11 presented to the facility's ER on February 27, 2014, at 4:22 p.m.

Medical record review of a Triage and Nursing History dated February 27, 2014, at 5:31 p.m., revealed, "...right side pain since 4 am (a.m.) sent bu (by) ob (obstetrician)...is 14 weeks pregnant..."

Medical record review of an untimed physician's (M.D. #6) ER Note dated February 27, 2014, revealed, "...14 wk (week) gest (gestation) c/o (complains of) RUQ (right upper quadrant) pain...FHT (Fetal Heart Tones) 150...R/O (rule out) nephrolithiasis/cholelithiasis..."

Medical record review of an order written by M.D. #6 dated February 27, 2013, revealed, "Discharge home."

Medical record review of the ER record revealed, "...Disposition...decision is discharge. Condition at disposition - stable..."

Medical record review of a nurse's note dated February 27, 2014, at 10:10 p.m., revealed, "...physically left department..."

Interview with the ER Manager on April 10, 2014, at 9:05 a.m., in a conference room, confirmed the facility failed to document the disposition of Patient #11 on the ER log dated February 27, 2014.