HospitalInspections.org

Based on the interview, observation of a video, and record review, the hospital failed to maintain an accurate Central Log in that 1 patient (P #1) of 20 patients (P #1 through P #20) sampled who came to the facility's emergency department seeking medical attention was not recorded in the Eemergency Department Log. This failed practice does not allow the hospital staff to track patients who come to the hospital for examination of a medical condition. This can affect patients requiring care in future visits if the patient's illness worsens.


Findings:


A. On 10/10/18 at 2:10 pm during interview, S #8 stated, "There was an Action Cue (incident report) completed: The family called Emergency Medical Services (EMS), they responded to the residence, he refused care and family wanted him to receive care so he was brought to the hospital . They brought him to the back door, [employee S #22] took a wheel chair out (to the vehicle), I saw this on video. [P #1] did not want to get out of the car. S #8 told the lead (staff) that this occurred and wrote a statement."


B. On 10/10/18 at 4:21 pm during interview, S #2 stated, "Nothing was documented as far as the patient not being seen or treated except what was written in the Action Cue."


C. On 10/11/18 at 7:30 am during an interview, S #12 stated, "It was not documented (Central Log) [P #1] came because he was not registered." (The regulation requires any person presenting at the E.D. to be logged into the hospital's central log).


D. On 10/11/18 at 7:55 am during an interview, S #22 confirmed being the staff who brought a wheelchair out to the truck to assist P #1 into the ED. S #22 stated, "I did not open the car door nor did the woman tell me the man's name."


E. Video review of footage from the evening of 08/16/18 at approximately 17:43 (5:43 pm) revealed a pickup truck entering the facility parking lot and pulling up next in front of the camera which appeared to be located above the facility's emergency department entrance door. A woman then got out of the truck and entered the facility; she then exited the facility with a female staff pushing a wheelchair. The staff with the wheelchair walked up to the truck passenger door while the woman driving the truck went to the driver's side of the truck and stood on the running board. Staff with the wheelchair backed away from the truck slightly and the woman got into the truck. Staff with the wheelchair headed back to the ED without the patient (due to patient's refusal) while the woman driving the truck left the parking lot.


F. Record review of facility's policy and procedures revealed the following:


1) Cobra/EMTALA Guidelines Policy, dated 05/2000, revealed the purpose of the policy is to provide an appropriate medical screening examination to people presenting at the Emergency Department requesting examination or treatment of a medical condition." The policy further states, under Procedure, Examination and Treatment: Medical Screening Evaluation - facility will provide a medical screening evaluation (MSE) for the purpose of determining whether an emergency medical condition exists, to "Any individual presenting at a dedicated department seeking examination and treatment of a medical condition, or on whose behalf a request is made", under the Documentation section, it states, "Emergency Patient Log. The central log for all individuals who come to an ED will be maintained for a minimum of five years."


2) Cobra/EMTALA Guidelines - Office of the Inspector General Standard for Compliance, created 09/2004, last revised and approved on 07/17 revealed facility "will follow the registration process for unscheduled walk-in areas including the ED in compliance with Federal Office of the Inspector General (OIG) standard for EMTALA compliance." The purpose of the policy is to provide guidance for facility registration and ED personnel on EMTALA Regulations." Special Procedures include "Following initial triage of a patient, the primary registration process may be started. At no time should the registration process interfere with or delay treatment. Registration information obtained from family or friends of the patient is subject to the same stands as that information obtained directly from the patient".

Based on observation, interview, and records review, the hospital failed to conduct a medical screening examination (MSE) for 1 (P#1) patient of 20 (P#1 through P#20) patients sampled who presented to the emergency department (ED) for an examination of a medical condition. This deficient practice placed the patient at risk for developing a potentially life threatening condition while being transported to another facility.


Findings:


A. On 10/10/18 at 4:21 pm during interview, S #2 stated, "Nothing was documented (Central Log) as far as the patient not being seen or treated except what was written in the Action Cue." (Incident Report)


B. On 10/11/18 at 7:30 am during an interview, S #12 confirmed that a medical screening examination (MSE) was not completed on P#1 and stated, "It was not documented, [P #1] because he was not registered."


C. On 10/11/18 at 7:55 am during an interview, S #22 confirmed being the staff who brought a wheelchair out to the truck to assist P #1 into the ED. S #22 stated, "I did not open the car door nor did the woman tell me the man's name".


D. Review of the hospital ED log reveals that the patient was not listed on the hospital's Central Log and there was not MSE conducted on P#1.


E. Video review of footage from the evening of 08/16/18 at approximately 17:43 (5:43 pm) revealed a pickup truck entering the facility parking lot and parking near the ambulance bay (where ambulance personnel enter the ED) doors. A woman got out of the truck and entered the facility; she then exited the facility with a female staff pushing a wheelchair. The staff with the wheelchair walked up to the truck passenger door while the woman driving the truck went to the driver's side of the truck and stood on the running board. Staff with the wheelchair backed away from the truck slightly and the woman got into the truck. Staff with the wheelchair headed back into the ED without the patient as the woman driving the truck exited the parking lot.


F. Record review of facility's policy and procedures revealed the following: Cobra/EMTALA Guidelines Policy, dated 05/2000, revealed the purpose of the policy is to provide an appropriate medical screening examination to people presenting at the Emergency Department requesting examination or treatment of a medical condition. The policy further states, under Procedure, Examination and Treatment: Medical Screening Evaluation - facility will provide a medical screening evaluation (MSE) for the purpose of determining whether an emergency medical condition exists, to "Any individual presenting at a dedicated department seeking examination and treatment of a medical condition, or on whose behalf a request is made."


G. Patient #1 was brought to the Eemrgency Department of a nearby acute care hospital which is an Indian Health Service (IHS) hospital. Review of the medical record at the IHS hospital revealed that Patient #1 was brought to the Emergency Department (ED) via a pricate vehicle on 08/16/2018 at 19:30. The patient was assisted by ED staff from the private vehicle to the ED. The medical record revealed that Patient #1 was brought to the ED following a fall while driving his motorized wheelchair on the sidewalk by his house. He complained of right lateral and lower chest pain. MSE was completed.



40164