HospitalInspections.org

Based on review of facility documentation and medical record review (MR), as well as employee interviews (EMP), it was determined the facility failed to ensure a central log was maintained on each individual who comes to the Emergency Department for one of 30 medical records reviewed (MR1).

Findings include:

Review, at approximately 12:21 PM on July 8, 2020, of "Compliance Overview," review dated November 2007, revealed "... I. Policy: It shall be the policy of Clarion Hospital to comply with the following EMTALA obligations: 1. Maintain a log on patients who come to the hospital seeking emergency services. Include EMTALA required information in all logs. This log must be retained for five years. ..."

Review, at approximately 2:01 PM on July 20, 2020, of "Deleting Accounts," dated July 6, 2020, revealed "... Under EMTALA we are required to maintain a central log of the individuals who come to the dedicated ED seeking treatment and indicate whether these individuals: Refused treatment; Were denied treatment; Were treated, admitted, stabilized, and/or transferred or were discharged. We are never to delete an account in [name of documentation system] because this is where we document the outcome of all presenting patients. Our required log is printed from [name of documentation system] . ..."

Review, at approximately 11:54 AM on July 21, 2020, of "Emergency Department Policy Number 12, Log Book, Register for Emergency Department Patients," revised May 2011, revealed, "I. Scope: Registration Secretary, RN, LPN; II. Purpose: To provide useful data to the hospital for long-range planning. The data may be utilized in determining statistical sampling for quality and utilization management studies; III. Text: Every patient who comes to the Emergency Department will be logged in the Emergency Department Register Log Book and the information to include is as follows: 1. Date and time of Emergency Department admission. 2. Patient account number. 3. Patient first and last name. 4. Patient's address, age, sex. 5. Attending physician and, if admitted to the hospital, the admitting physician. 6. Mode of arrival. 7. Nature of injury/illness. 8. Service rendered. 9. Check mark for admission and ID bracelet. 10. Disposition of patient (treated/released, admitted to hospital, transferred to another facility, or death in the ER). 11. Discharge time/admit to hospital time and room number, and condition on discharge. 12. Whether the patient has event [sic] been a patient at the hospital, in order to facilitate coordination of medical records. ..."

Review, at approximately 1:52 PM on July 21, 2020, of "Nursing Policy Number 20, Patient Log Book," revised September 2011, revealed, "I. Scope: Registration Secretary, RN, LPN II. The purpose of central log is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition. To ensure documentation of every person who presents for treatment. To provide useful data to the hospital for long-range planning. The data may be utilized in determining statistical sampling for quality and utilization management studies. III. Responsible Party: Emergency Department staff, Labor and Delivery, Registration: A. Emergency Department: Every patient who comes to the Emergency Department is logged electronically and the information to include is as follows: 1. Date and time of arrival. 2. Medical Record number. 3. First and last name. 4. Address, age. 5. Attending Emergency Department physician and, if admitted to the hospital, the admitting physician. 6. Mode of arrival. 7. Nature of injury/illness/complaint. 8. Service rendered (will be hand written on printed electronic log). 9. Disposition of patient (treated/released/refused treatment, admitted to hospital, transferred to another facility, or death in the ER). 10. Discharge/admit time (room number, if applicable). 11. Condition on discharge. 12. Whether the patient has even been a patient at the hospital, in order to facilitate coordination of medical recor [sic] ..."

1. Review, at approximately 3:13 PM on July 7, 2020, of physician documentation in [MR1] revealed this patient arrived at the ER at 19:59 on July 2, 2020, and was initially turned away by the registration staff.

2. Review of MR2 through MR17 from approximately 9:30 AM-11:50 AM on July 21, 2020, revealed compliance with Federal Conditions of Participation.

3. Review of MR18 through MR30 from approximately 1:00 PM-2:30 PM on July 21, 2020, revealed compliance with Federal Conditions of Participation.

4. Review at approximately 11:26 AM on July 8, 2020, of the Emergency Department Daily Log, revealed [MR1] arrived at approximately 7:56 PM on July 2, 2020 to the Emergency Department. Further review did not reveal prior documentation of [MR1] coming to the Emergency Department at approximately 7:17 PM on July 2, 2020.

5. At approximately 12:50 PM on July 16, 2020, EMP2 entered the conference room and presented additional documentation that was recently received as a result of the facility's internal investigation ["Employee Interviews," dated July 3-7, 2020]. EMP2 stated, "Initially, [EMP6] said [he/she] wasn't aware of the event, however, upon further investigation, we found out [he/she] was aware. [He/She] was given a verbal warning for not alerting [his/her] supervisor when [he/she] became aware of the situation."

6. Review, at approximately 1:04 PM on July 20, 2020, of an internal facility communication, "Employee Interviews," dated July 3-7, 2020, revealed, "... [EMP10] said, '[He/She] came over, I asked DOB [date of birth] and age. I thought [he/she] said 19. I think that came from [his/her] DOB. I got [him/her] registered and saw [he/she] was only 16. I asked [him/her] if [he/she] had an adult with [him/her]. When I figured out [his/her] age, it throwed [sic] me off and I told [him/her] that we couldn't see [him/her] without an adult.' Patient said, 'Ok and then got up and walked out.' I then cancelled the account. ..."

7. Review, at approximately 1:59 PM on July 20, 2020, of "Deleted Accounts," dated July 14, 2020, revealed, "... Event Code: A11; Patient #: 3,774,084; Username: [EMP10]; Date: 2020-07-02; Time: 19.17.31 ..."

8. When asked, at approximately 9:03 AM on July 24, 2020, if [he/she] could confirm that [MR1] should have been listed on the Emergency Department's Daily Log for [his/her] initial visit on July 2, 2020, EMP2, "Yes. I can confirm that he should have been listed."

Based on review of facility documentation, medical record review (MR), and employee interviews (EMP), it was determined the facility failed to provide an appropriate medical screening examination within the capabilities of the hospital's Emergency Department for one of 30 medical records reviewed (MR1).

Findings include:

Review, at approximately 12:52 PM on July 8, 2020, of "Patient Medical Screening," revision dated July 2019, revealed "... A. Medical Screening Examination: 1. Clarion Hospital shall provide for an appropriate medical screening examination within the capability of the hospital's Emergency Department and Obstetrical Department including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exists; 2. The medical screening examination: a. Shall be sufficient to detect or rule out an emergency medical condition; b. Shall be the same provided to all patients with similar conditions regardless of the patient's financial status, insurance, color, national origin, or handicap; ..."

Review, at approximately 9:33 AM on July 21, 2020, of "Emergency Department Policy Number 1, Scope/Purpose, Emergency Department," revised May 2014, revealed "... II. Purpose: Clarion Hospital Emergency Department offers emergency care 24-hours a day, seven days a week with an in-house physician. ... III. Text. Any individual who comes to Clarion Hospital for emergency medical evaluation or initial treatment shall be properly assessed by qualified individuals and appropriate services shall be rendered within the defined capability of Clarion Hospital. ... 3. To ensure all patients receive an Emergency Medical Screening by an emergency physician, certified registered nurse practitioner, or a physician's assistant. ... 7. To guide emergency patient care accepted by standards of practice and by written policies and procedures. ..."

Review, at approximately 11:10 AM on July 21, 2020, of Emergency "Department Policy Number 4, Minors, Emergency Treatment of," revised April 2008, revealed "... II. Purpose: To establish guidelines for effective consent to treat a minor. ... III. Text: ... 1. An individual may consent to treatment if any one of the following conditions are met: A. The individual is 18 years or older. B. the individual is a high school graduate. C. The individual is or has been married. D. The individual has been pregnant. ... 2. If criteria is not met in A to D, then effective consent must be obtained from the minor's parent or legal guardian. The consent of a minor is ineffective. Consent of only one parent or legal guardian is necessary. The medical screening exam may be performed without consent. If an emergency medical condition is ruled out, then treatment will not be initiated without consent. 3. Proof of valid consent is required. Written consent is preferred, but oral consent, if documented, is just as binding. Telephone consent must be documented by two witnesses (RN, LPN, PA, Secretary). 4. If, in the physician's judgement, an attempt to secure consent would result in the delay of treatment thereby increasing the risk to the minor's life or health, consent is then not necessary. Requirements for the physician to negate the need for consent are: A. There is a threat to the life or health of the patient. B. the threat is deemed to be an immediate one. C. The physician and hospital have documented the medical need for proceeding with treatment without consent and any attempts to secure consent were unsuccessful because of unavailability of a person to give consent. ..."

1. Review, at approximately 3:13 PM on July 7, 2020, of physician documentation in [MR1] revealed this patient did not receive an appropriate medical screening examination during [his/her] initial visit when [he/she] arrived 30 minutes prior and was initially turned away by registration staff.

2. Review of MR2 through MR17 from approximately 9:30 AM-11:50 AM on July 21, 2020, revealed compliance with Federal Conditions of Participation.

3. Review of MR18 through MR30 from approximately 1:00 PM-2:30 PM on July 21, 2020, revealed compliance with Federal Conditions of Participation.

4. When asked, at approximately 9:38 AM on July 16, 2020, if the patient should have had a medical screening examination during [his/her] initial visit, EMP2 stated, "Yes."