HospitalInspections.org

Based on document review and staff interview it was determined the facility failed to ensure staff complied with the regulations for EMTALA at 489.20 and 489.24. The facility failed to provide an appropriate MSE to an individual who presented to the emergency department (see tag A-2406).

Based on document review and staff interview it was determined the facility failed to maintain a daily patient log on all patients who come to the emergency department seeking care for an emergency medical condition. Review of the ED log revealed no entry for Patient #1. This failure has the potential to negatively impact the care given to all patients who present to the emergency department for treatment.

Findings include:

1. The policy "Control Register", last approved 01/16 states in part: "It is the policy of the Emergency Department to maintain a daily patient log on all patients presenting to the department. This log is maintained permanently and computer generated.

2. Review of the ED log revealed no entry for Patient #1.

3. An interview was conducted with the ED Manager on 10/26/17 at 1:00 p.m. She stated: "When a patient presents to the emergency room seeking medical treatment they should be registered and entered into the emergency room log. The patient can then be triaged and seen by the physician". She concurred with the findings.

Based on document review and staff interview it was determined the facility failed to provide an appropriate medical screening examination for one (1) (patient #1) out of twenty (20) medical records reviewed who presented to the ED seeking emergency care. This failure has the potential to negatively impact the care given to all patients who present to the emergency department for treatment.

Findings include:

1. The policy, "Medical Screening, Treatment, Transfer and Consultation" last reviewed 01/16 states in part: "Screening: Any individual who presents at the emergency department will be provided a medical screening examination to determine the need for emergency medical treatment.

2. Review of the ED log revealed no entry for Patient #1. This patient presented to the ED with thoughts and actions of suicidal ideation and was not registered or given an appropriate medical screening examination to determine the need for emergency medical treatment.

3. Review of the on-call physician schedule for the ED revealed a psychiatrist was available to conduct an appropriate medical screening examination on the patient.

4. An interview was conducted with the ED manager on 10/26/17 at 1:00 p.m. She stated: "When the patient presented to the emergency department for treatment my expectation would be to have her registered, put on the ED log and given an appropriate medical screening examination". She concurred with the findings of the patient not being medically screened when she presented to the ED for treatment.