HospitalInspections.org

Based on interview and record review, the hospital failed to follow it's policy and procedure to log all patients presenting to the emergency department which had the potential to result missing information to determine if all patient care needs were met.

Findings:

During a concurrent interview with the Quality Improvement Manager (QIM), on 10/21/15 at 10:10 AM and review of the electronic emergency department patient log, the patient list for 10/13/15 was reviewed. There was no entry for Patient 10 noted on the log. This was confirmed by the QIM.

During an interview with Registered Nurse (RN) 1 on 10/21/15 at 11:45 AM, she stated she was the nurse on duty in the emergency department when Patient 10 arrived at the hospital. She stated the hospital received a call on the radio from the ambulance staff stating they were in route with a patient with a possible hip dislocation. She stated when Patient 10 arrived, she was at the hospital for less than five minutes before the paramedic reloaded Patient 10 into the ambulance and drove away because Patient 10 refused to stay. RN 1 stated she did not have time to triage Patient 10, take her vital signs, or prepare a chart. She stated there was no entry of Patient 10 into the emergency department log.

The hospital policy and procedure titled "Emergency Department Patient Registration", dated 11/2007, indicated "All Emergency Department patient information will be maintained in a central log..."