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515 5TH AVE WEST

GRAND MARAIS, MN 55604

COMPLIANCE WITH 489.24

Tag No.: C2400

Based on documentation review and interview the hospital failed to ensure compliance with requirements at 42 CFR 489.24 as evidenced by the deficient practice cited at 42 CFR 489.20(l), 489.20(q), 489.20(r) and 489.20(r)(3).

The hospital failed to ensure all patients who entered the emergency department (ED) knew their rights under section 1867 of the Social Security Act, were entered into the central log and had their records maintained for 5 years.

POSTING OF SIGNS

Tag No.: C2402

Based on observation and interview, the hospital failed to conspicuously post in the emergency department or in a place or places likely to be noticed by all individuals under section 1867 of the Social Security Act with respect to examination and treatment in the emergency room.

Findings include:

On 12/26/18, at 1:11 p.m. a tour of the emergency department (ED) was conducted with the administrator and registered nurse (RN)-A. The hospital had three entrances into the ED: the main entrance with a hallway which led to the ED triage room, ED waiting room and the ED; the staff entrance which patients also used; and the ambulance/private vehicle entrance. There was an EMTALA sign in the ED waiting room, inside the door of the ED entrance, and in the ED triage room. The hospital failed to have an EMTALA sign in the ambulance bay or inside the entrance into the ED visible from the ambulance bay specifying the rights of individuals under section 1867 of the Social Security Act with respect to examination and treatment for emergency medical conditions and women in labor (EMTALA). There were no individual EMTALA signs in individual ED rooms for individuals to view while waiting for an examination. The administrator acknowledged there was no sign visualized from the ambulance bay into the ED.

On 12/26/18, at 4:15 p.m. RN-A verified there was no EMTALA sign visible from the ambulance entrance into the ED.

HOSPITAL MUST MAINTAIN RECORDS

Tag No.: C2403

Based on interview and document, the hospital failed to maintain medical records for at least a period of five years for 1 of 22 patients (P12) reviewed.

Findings include:

P12's central log review for 8/13/18, at an unknown time for visit V2067080, indicated P12 presented to the ED by family vehicle, with shortness of breath. The individual left without being seen. There was a Post-it note attached to the central log that there were, "No notes, Left AMA before nursing triage."

On 12/27/18, at 12:00 p.m. registered nurse (RN)-C was interviewed. RN-C stated when she triaged P12 on 8/13/18, he wanted to stay at North Shore Hospital. P12's wife wanted him to go to Duluth. Later, the receptionist called RN-C to inform her P12 and his wife left the lobby to go to Duluth. RN-C did not remember if she wrote a note in P12's medical record.

On 12/27/18, at 2:45 p.m. RN-A was interviewed and stated P12's central log was not on the computerized version of the ED central log, as it was deleted from the medical records program on 8/13/18, by the registration staff. RN-A stated Internet technology (IT) staff retrieved the deleted record today to review it. It indicated the record was deleted on 8/13/18, at 10:04 p.m., and the nurse's triage note was at 9:17 p.m. RN-A verified deletion of the record was not within EMTALA requirements.

The North Shore Health EMTALA (Emergency Medical Treatment and Active Labor Act) revised 6/21/17, directed "5. The Emergency Department maintains a central log of all individuals who come to the hospital to seek assistance. a. The log is maintained for a minimum of five (five) years. b. The log will indicate if the individual was: 1. Treated and discharged, 2. Admitted and treated, 3. Stabilized and transferred, 4. Refused treatment, 5. Left against medical advice (AMA), or 6. Left before being seen.

EMERGENCY ROOM LOG

Tag No.: C2405

Based on interview and document review, the hospital failed to maintain an accurate and complete central log on each individual who presented to the emergency department (ED) for 2 of 22 patients (P10, P12) reviewed.

Findings include:

P10's central log notes indicated P10 presented to the ED on 8/13/18, at an unknown time, with a chief complaint of "Cardiac." There was no disposition noted on the ED log.

P12's central log notes indicated P12 presented to the ED on 8/13/18, at an unknown time, with shortness of breath. P12 left without being seen. There was a Post-it note attached to the central log that there indicated, "No notes, Left AMA before nursing triage." P12 was not listed on the computer print out of the ED central log.

On 12/26/18, at 4:15 p.m. registered nurse (RN)-A was interviewed, and confirmed the central logs for the ED for 8/13/18, and other dates were incomplete.

The North Shore Health EMTALA (Emergency Medical Treatment and Active Labor Act), policy revised 6/21/17, directed "5. The Emergency Department maintains a central log of all individuals who come to the hospital to seek assistance. a. The log is maintained for a minimum of five (five) years. b. The log will indicate if the individual was: 1. Treated and discharged, 2. Admitted and treated, 3. Stabilized and transferred, 4. Refused treatment, 5. Left against medical advice (AMA), or 6. Left before being seen.