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Based on interview, record review, review of facility EMTALA logs, and review of facility policies, the facility failed to ensure medical records were complete, accurate and retained for each individual seeking treatment at the facility. This affected 17 (Patients #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25) of 25 patients reviewed.

Findings include:

1. Review of the Emergency Medical Treatment and Labor Act (EMTALA) log dated 11/02/23 revealed Patient #2 presented to the hospital on 11/02/23 at 8:28 A.M. per car, received medical screening at 8:30 A.M., and was referred to another hospital at 9:40 A.M.

Review of form titled "Medical Send Out and EMTALA" dated 11/02/23 revealed Patient #2 presented for complaints including alcohol detoxification, Suicidal Ideation (SI), and psychotic behaviors, vital signs were assessed, and the patient left in serious condition per scheduled medical transport to another hospital emergency department (ED) due to the hospital was at capacity and there were no beds available for admission.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

2. Review of the EMTALA log dated 110/0/23 revealed Patient #10 presented to the hospital on 11/08/23 at 1:50 P.M. per car with complaints of SI and psychotic behaviors, received medical screening at 2:00 P.M. and was transferred to another hospital in fair condition via 911/EMS personnel.

Further review of the medical record revealed there was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

3. Review of the EMTALA log dated 11/02/23 revealed Patient #11 presented to the Hospital on 11/02/2203 at 11:48 AM via car with complaints of paranoia and other psychotic behaviors, received medical screening at 11:50 A.M., and was transferred to another hospital ED at 1:01 P.M. via 911/EMS personnel.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

4. Review of the EMTALA log revealed Patient #12 presented to the hospital on 11/01/23 at 9:29 A.M. via car with complaints of Homicidal Ideation (HI) and SI with a plan, was medically screened at 9:30 A.M., and was transferred at 10:40 A.M. in fair condition to unidentified ED via 911/EMS personnel.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

5. Review of the EMTALA log revealed Patient #13 presented to the hospital on 11/02/23 at 1:26 P.M. per walk-in with complaints of cocaine relapse, received medical screening at 1:30 P.M., and was transferred at 2:14 P.M. in fair condition via EMS/911 personnel to an unidentified ER.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

6. Review of the EMTALA log revealed Patient #14 presented to the hospital on 10/25/23 at 2:22 P.M. per walk-in with complaints of HI with a vague target and SI with a plan, received medical screening at 2:23 P.M., and was transferred at 3:28 P.M. in fair condition to another facility for treatment via a private vehicle.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

7. Review of the EMTALA log revealed Patient #15 presented to the hospital on 11/25/2203 at 8:00 A.M. via walk-in with complaints of depression, anxiety, substance abuse. The patient received medical screening at 8:05 A.M. and was transferred to another facility for treatment via private vehicle at 9:05 A.M. in fair condition.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

8. Review of the EMTALA log revealed Patient #16 presented to the hospital on 11/25/23 at 4:40 A.M. via car with complaints of SI with a plan, received medical screening at 4:45 A.M., and was transferred in fair condition to another hospital via scheduled medical transport.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

9. Review of the EMTALA log revealed Patient #17 presented to the hospital on 12/17/23 at 6:47 P.M. via car with complaints of SI and HI, received medical screening at 6:52 P.M., and was transferred in fair condition via 911/EMS personnel at 12:15 A.M. to an unspecified destination.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

10. Review of the EMTALA log revealed Patient #18 presented to the hospital on 11/28/23 at 12:53 P.M. via walk-in with complaints of SI, received medical screening at 12:55 P.M., and was transferred in fair condition at 7:10 P.M. via scheduled medical transport to another hospital.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

11. Review of the EMTALA log revealed Patient #19 presented to the hospital on 01/25/23 at 2:15 P.M. via car with unspecified complaints, received medical screening at 2:18 P.M., and left in good condition in a private vehicle. The patient did not meet criteria for admission.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

12. Review of the EMTALA log revealed Patient #20 presented to the hospital on 10:25 A.M. via car with complaints HI/SI and psychotic behavior, received medical screening at 11:00 A.M., and was transported in fair condition via 911/EMS at 12:45 P.M. to an unspecified ED.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

13. Review of the EMTALA log revealed Patient #21 presented to the hospital on 01/08/24 at 8:30 P.M. via walk-in with complaints of alcohol detox, received medical screening at 8: 32 P.M., and was transferred via 911/EMS personnel in serious condition to another ED.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

14. Review of the EMTALA log revealed Patient #22 presented to the hospital on 12/05/23 at 5:45 P.M. via walk-in with complaints of SI, received medical screening at 5:50 P.M., and was transferred via scheduled transport in fair condition to another ED.


There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

15. Review of the EMTALA log revealed Patient #23 presented to the hospital on 12/04/23 at 2:30 P.M. via walk-in with complaints of SI, received medical screening at 2:35 P.M., and was transferred via scheduled medical transport in fair condition to an unidentified location.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

16. Review of the EMTALA log revealed Patient #24 presented to the hospital on 11/08/23 at 2:33 P.M. via car with complaints of SI/HI with a plan and psychotic behaviors, received medical screening at 2:36 P.M., and was transferred in fair condition vie 911/EMS personnel to another hospital.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

17. Review of the EMTALA log revealed Patient #25 presented to the hospital on 12/12/23 at 2:19 P.M. via car with complaints of SI and substance use, received medical screening at 2:20 P.M., and was transferred in fair condition via 911/EMS personnel to another hospital.

There was no documentation of consents for assessment, Initial Medical Screen, or Level of Care Assessment contained in the record.

During an interview on 02/08/23 at 12:21 P.M. Staff E stated every individual who presented for emergency treatment was logged into the EMTALA log. Walk-in patients signed a consent for assessments and a Urine Drug Screen. Nurse were required to complete a medical screening examination with vital signs within 15 minutes of each patient's arrival. Intake staff completed a Level Of Care (LOC) assessment which included the presenting problems and medical history. After the assessment, staff called the provider to see if the patient was approved for admission. If the patient did not meet criteria for admission, staff determined if the individual had an outpatient provider or assisted to set up outpatient services as applicable, and everything was documented in the medical record. Medical records were filed in filing cabinet and kept for one month before moved to medical records.

During an interview on 02/08/23 at 12:30 P.M. Staff A verified there were 17 patient records that were incomplete and the only record of visits for Patients #2, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25 were what was include on the EMTALA logs and on the Medical Send Out/EMTALA forms. Staff A stated there had been recently hired staff who had confusion about how files were stored and had shredded parts of the medical records.

Review of policy titled "Emergency Medical Treatment and Active Labor Act" dated 03/23 revealed a medical record was established for each individual seeking emergency treatment including documentation of the individual's medical and psychiatric history, screening examination, diagnosis (if determined), treatment rendered, response to treatment, and disposition of case. Additionally, any conclusions or findings that indicated the individual did not have a medical emergency condition were documented in the medical record. The facility maintained medical records and documentation associated with the appropriate transfer of patient, including the log for seven years.