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Based upon medical record review, document review and interview, the facility did not comply with all the provisions for maintaining a central log and conducting a medical screening exam.

Please reference findings under Tag A 2405 and 2406.

Based on policy review, medical record review, document review and interview, the facility did not ensure all individuals presenting to the Emergency Department (ED) are entered into the central log for 1 of 21 patients (Patient #1). Not entering a patient in the central log could result in a patient not receiving a medical screening exam.

Findings include:

Review on 09/25/18 of policy "Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfers" dated 12/04/17 indicates patients who present to the ED will be registered in the patient information system and in the central log after triage. The date and time of arrival, name, address, date of birth and nature of their complaint should be recorded. If a patient leaves before triage or registration, available information will still be entered into the central log.

Telephone interview on 09/26/18 at 01:35 PM with Staff (V), Registration Clerk, revealed a " mother " and young boy came into the ED asking for a pediatric social worker. Staff (V) contacted Staff (H), Social Worker, who came down to speak with them.

Telephone interview on 09/26/18 at 11:10 AM with Staff (H), Social Worker revealed a " mother " and male child came to the ED, presented to the registration desk and inquired about seeing a pediatric social worker. The mother indicated that " the school " wanted a psychiatric evaluation for her child. Staff (H) told the mother that an evaluation could be done there. The mother indicated that the last time she brought her daughter here, they were here all weekend and asked about other local facilities where she could take her child to. Staff (H) gave her the names of psychiatric units, indicating the type of programs they have. Prior to leaving, Staff (H) stated that the child could be seen here, but if he needed admission, the child would need to be transferred. No patient information was given to Staff (H) by the mother and the patient was not registered.

Review on 09/25/18 of the ED Central Log for September 2018 revealed Patient #1 was not entered into the log.

Medical record review on 09/25/18 at 04:15 PM with Staff (E), Assistant ED Manager revealed no evidence that a medical record was generated for Patient #1.

Based on policy review, medical record review, document review and interview the hospital did not provide a medical screening exam (MSE) for 1 of 21 patients who presented to the Emergency Department (Patient #1). A lack of a MSE could result in an emergency medical condition not being identified and treated.

Findings include:

Review on 09/25/18 of policy "Medical Screening Examinations, Stabilizing Treatment and Appropriate Transfers" dated 12/04/17 indicates patients who present to the ED will be registered in the patient information system and in the central log after triage. The date and time of arrival, name, address, date of birth and nature of their complaint should be recorded. If a patient leaves before triage or registration, available information will still be entered into the central log.

Review on 09/25/18 of the " Medical Staff Rules & Regulations " dated 12/14/17 indicates patients coming to the ED requesting evaluation and treatment will have a medical screening examination as required by Federal law by a qualified medical professional (Physicians, Physician Assistants, Nurse Practitioners and trained obstetrical nurses in consultation with an OB provider).

Telephone interview on 09/26/18 at 01:35 PM with Staff (V), Registration Clerk, revealed a " mother " and young boy came in asking for a pediatric social worker. Staff (V) believes the mother and child were referred from school, looking for an evaluation and weren ' t sure where to go. The mother had a paper in her hand. Staff (V) called Staff (H), Social Worker, who came down to talk with them.

Telephone interview on 09/26/18 at 11:10 AM with Staff (H), Social Worker revealed a " mother " and male child came to the ED, presented to the registration desk and inquired about seeing a pediatric social worker. The mother indicated that " the school " wanted a psychiatric evaluation for her child. Staff (H) told the mother that an evaluation could be done there. The mother indicated that the last time she brought her daughter here, they were here all weekend and asked about other local facilities where she could take her child to. Staff (H) gave her the names of psychiatric units, indicating the type of programs they have. Prior to leaving, Staff (H) stated that the child could be seen here, but if he needed admission, the child would need to be transferred. No patient information was given to Staff (H) by the mother and medical screening exam was not conducted.

Medical record review on 09/25/18 at 04:15 PM with Staff (E), Assistant ED Manager revealed no evidence that a medical record was generated for Patient #1.

Review on 09/27/18 of the ED medical record from another hospital revealed on 09/14/18 at 04:01 PM Patient #1 arrived at their facility. The patient presented with a referral from the school social worker for a psychiatric evaluation after a friend reported that the patient intended to kill himself. The patient was triaged and had a MSE with psychiatric consultation. Patient #1 remained in the ED until 09/17/18 when he was transferred to an inpatient Adolescent Psychiatric Center.