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Based on document review and interview, the facility failed to comply with 489.24 for 2 (Patient #1 & 2) of 20 individuals presenting to the Emergency Department (ED).

Findings include:

1. See under tag 2406 (489.24 (c) & (r) ).

Based on interview and document review, the facility failed to to maintain a central log on each individual who comes to the emergency department, seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 2 of 20 individuals presenting to the Emergency Department (patient #1 & 2).

Findings include:

1. Review of policy/procedure 10.14, Emergency Room Patient Log & Change in Treatment Log, indicates the following:
"Emergency Room Patient Log is maintained by patient registration it is to include:
Date Time Mode of Arrival
Age Sex name of Patient
Nature of complaint
Brief description of services provided
Disposition
Condition on discharge
Time of Discharge"
This policy/procedure was last reviewed/revised on 05/10.

2. Review of the Emergency Department Registration Sign-in Sheet dated 10-21-10 indicates that patient
#1 presented to the Emergency Department on 10-21-10 at 1000 hours. Review of the Emergency Department Registration Sign-in Sheet dated 09-30-10 indicates that patient #2 presented to the Emergency Department on 09-26-10 at 0945 hours.

3. Review of the Emergency Department Patient Log Book lacks documentation that patient #1 was recorded as presenting to the facility Emergency Department on 10-21-10 and the disposition of the patient. Review of the Emergency Department Patient Log Book lacks documentation that patient #2 was recorded as presenting to the facility Emergency Department on 09-26-10 and the disposition of the patient. There was no documentation to indicate patient #1 and #2 refused exam or treatment.

4. On 11-17-10 at 1345 hours staff #40 confirmed that patient #1 & 2 visits to the Emergency Department was not documented in the Emergency Department Log Book.

Based on interview and document review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists for 2 of 20 individuals who presented to the Emergency Department (Patient #1 & 2).

Findings include:

1. Review of policy/procedure 13.1, Triage in the Emergency Department, indicates the following:
"Purpose
According to EMTALA all hospitals are to provide appropriate screening examinations to determine if a medical emergency exists and to treat and stabilize this condition regardless of ability to pay, race, creed, or color.
The hospital must provide an appropriate medical screening examination within E.R. including ancillary services when applicable to provide the information necessary to determine a medical emergency.
This policy/procedure was last reviewed/revised on 03/10.

2. Review of the Emergency Department Registration Sign-in Sheet dated 10-21-10 indicates that patient #1 presented to the Emergency Department on 10-21-10 at 1000 hours. Review of the Emergency Department Registration Sign-in Sheet dated 09-29-10 indicates that patient #2 presented to the Emergency Department on 09-26-10 at 0945 hours.

3. Review of the Emergency Department Patient Log Book lacks documentation that patient #1 was recorded as presenting to the facility Emergency Department on 10-21-10 and the disposition of the patient. Review of the Emergency Department Patient Log Book lacks documentation that patient #2 was recorded as presenting to the facility Emergency Department on 09-26-10 and the disposition of the patient.

4. On 11-17-10 at 1345 hours staff #40 confirmed that patient #1 & 2 visits to the Emergency Department was not documented in a medical record.

5. There was no written evidence that a medical screening exam was performed by a physician and/or other qualified practitioner on patient #1 and #2.

6. There was no documentation to indicate refusal of exam or treatment by patient #1
and #2.