HospitalInspections.org

Based upon document review and interview, the facility did not comply with all of the provisions for maintaining a central log and conducting a medical screening exam. Please reference findings under Tag A2405 and A2406.

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

Findings:

Review of ENH -Nursing TRIAGE: (Emergency Severity Index) ESI Policy revised 1/10/12 reviewed 12/19/14. Triage is the process by which the RN prioritizes patients (according to severity of illness or injury and level of resources needed by the patient) upon arrival to the Emergency Room. Every Patient that presents to the ED is triaged and assigned an ESI number.

Interview with Staff # 3 RN, ED dated 8/26/15 at 9:30AM revealed that it is the expectation that every patient who presents to the ED is entered into the ED central log.

Review of the ED central log dated 8/7/15 to 8/9/15 revealed the patient was not entered into the log.

On interview on 8/26/15 at 8:45AM, Staff #11, ED physician stated that he was familiar with the patient as the patient presents to the ED frequently and on 8/8/15 "it was probably me who spoke with the patient". Staff # 11 indicated that when the patient presents, he goes out to the waiting room and asks the patient if there is anything wrong. The patient is then reassured and sent on his way. It was noted that there probably is not a record for the patient on 8/8/15 because he was not registered.

Interview with Staff # 1 on 8/26/15 verified the above finding.

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

Findings include:

Review of the facility's Emergency Medical Treatment and Active Labor Act (EMTALA) Policy 4.2 revised 8/2013 reviewed 3/2015 revealed that any patient presenting to the hospital and requesting treatment for a medical condition, will receive a medical screening exam by a physician to determine if an emergency medical condition exists.

On interview on 8/26/15 at 8:45AM, Staff #11, ED physician stated that he was familiar with the patient as the patient presents to the ED frequently and on 8/8/15 "it was probably me who spoke with the patient". Staff # 11 indicated that when the patient presents, he goes out to the waiting room and asks the patient if there is anything wrong. The patient is then reassured and sent on his way. It was noted that there probably is not a record for the patient on 8/8/15 because he was not registered.

Medical record review revealed no documentation of an ED visit and medical screening exam on 8/8/15 for Patient #1.

Interview with Staff # 12 RN, ED regarding Patient #1 and the date of 8/8/15 was conducted on 8/26/15 at 8:55am. Staff #12 stated " I don ' t remember that particular day. The doctors go out and talk to him (Patient #1) to ensure nothing is going on and reassure him and he is always smiling when he leaves. He comes in here a lot and just needs that reassurance".

This finding was verified with Staff #1 on 8/26/15 at 8:45AM.