HospitalInspections.org

Based on interview and record review the facility failed to comply with 489.24. See Tag C2405, and C2406,

Based on record review, interview and policy review, it was determined that the facility failed to maintain a central log documenting evaluation and treatment for 1 of 20 patients (Patient #1) that presented to the emergency department. Findings include:

On 06/28/11 at approximately 1400, the document titled "EMTALA Guidelines for Emergency Department Services was reviewed. It states under "Medical Screening Exam" that every Medical Screening Exam "should include at a minimum. . . Emergency Department Log entry including disposition of patient."

During a phone interview on 06/28/11 at approximately 1500 with Nurse #1, it was confirmed that Patient #1 did enter the ED on 06/12/11 1400 with a complaint of left lower quadrant and pelvic area pain and left the facility without being treated (see A2406). A document titled "Patient Information" for Patient #1 had the admit date of 06/12/11 with an admit time of 1229. When Registered Nurse #1 was queried in regards to the difference in the time of documentation, she stated "She (Patient #1) wasn't registered (on 06/12/11), that's why the time is off. She was registered the following day."

During an interview with the Quality/Risk Manager on 6/28/11 at it was confirmed that the ER Log contained the name of a patient logged in at 1205. The next patient was logged in at 1405. The ER log did not contain an entry or any information for Patient #1 who entered the ER at 1400 on 6/12/11.

Based on record review and interview, it was determined that the facility failed to ensure an adequate medical screening exam was performed to rule out an emergency medical condition for 1 of 20 patients (Patient #1) that presented to the emergency department. Findings include:

A female patient (Patient #1) presented to the ED on 6/12/11 at approximately 1400 with a complaint of left lower quadrant and pelvic area pain. During a phone interview on 6/28/11, Patient #1 stated that when these symptoms were shared with nursing staff (Nurse #1), the patient was informed that an ultra sound was indicated, but could not be provided at the facility that day. According to Patient #1, Nurse #1 stated that " there was no point in seeing you " and discussed other places where an ultra sound may be available. Patient #1 stated that she was never seen in an examination room or checked in (the interaction with Nurse #1 took place in a public waiting area) and when Nurse #1 said told her that she should be able to drive, Patient #1 decided to transport herself to one of the facilities mentioned as being able to provide ultra sound services and left the ED alone at approximately 1415.

There was no documentation that a Medical Screening Exam was performed for Patient #1 on 06/12/11.

During policy review on 06/28/11 at approximately 1400, a document titled " EMTALA Guidelines for Emergency Department Services " was reviewed. The content includes "All patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis."

During interview on 6/28/11 at approximately 1500, Nurse #1 recalled that Patient #1 walked into the ED on 6/12/11 during a period when the ED was " full " with acute cases. Nurse #1 recalled that Physician #1 had observed the patient when she arrived and later stated that no ultra sound was available. Nurse #1 also recalled discussing the lack of ultra sound services with the patient, discussing facilities that had ultra sound services and recalled that Patient # left with an adult driver. Nurse #1 denied telling the patient that she needed to go elsewhere. When asked about the lack of intake documentation or medical screening exam, Nurse #1 stated that she would usually write events in a chart, but did not for Patient #1. Nurse #1 stated that she made partial notation of Patient #1 ' s visit later on 6/12/11 (at approximately 1900).

During an interview on 06/28/11 at approximately 1345, the Director of Nursing stated, "I met with (Nurse #1) on June 27th from approximately 1130 to 1200 noon. I asked her to give a synopsis of the situation that happened on June 12th. According to the DON, Nurse #1 stated that Patient #1 entered the ED and sat on the bench. Patient #1 then told me her signs and symptoms. Nurse #1 stated that Physician #3 was sitting at the desk and overheard the conversation and told Patient #1 "We would be happy to see you, we do not have ultra-sound on the weekend." Nurse #1 told her they do at Facility#2 and Facility #3. Patient #1 said that her Dr. is from Facility #2 so she would go there and left with her mom. Nurse #1 stated that, "I called Facility #2 to give the name, and the date of birth of Patient #1. "

During interview on 6/28/11, Physician #1 recalled that he saw Patient #1 walk in alone on 6/12/11, then told Patient #1 to have a seat and that a nurse would be seeing her soon. Physician #1 also recalls telling Patient #1 that " We are happy to see you here. " and knew that the patient had left the ED after a short period.

A " Emergency Room Report " narrative dated June 12, 2011 at 1900 by Physician #1 relative to the visit of Patient #1 includes: " This patient was in the emergency department earlier this afternoon. The patient was never registered. She did have a screening exam by the emergency department nurse. " It also states, " I understand the nursing staff did obtain vital signs. After the nurses screen exam, the patient did leave. I did not examine the patient or do any additional history or physical on the patient. I did not do a physical exam the patient. "