HospitalInspections.org

Based on observation during a tour it was determined that the facility failed to conspicuously post EMTALA signage in all areas where patients are waiting for examination and treatment.

Findings include:

1. On 6/29/16 at 2:00 PM the Observation Unit was toured in the presence of Staff #2, #3, #6, and #21.

2. Observation Bays #9, #10, #11, #12, #20, #21, #22, and #23 did not have EMTALA signage posted in an area likely to be noticed by patients in these bays.

A. Based on review of the ED Log and medical records, and staff interview, it was determined that not all log entries are accurate.

Findings include:

1. Documentation in Medical Record #15 states the disposition of the patient as "Discharge Home."

2. Documentation on the ED log states the disposition of the patient as "LWBT" (Left without being treated).

3. The above findings were confirmed by Staff #3.



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B. Based on review of the Labor and Delivery (L&D) Daily Log and medical record review, it was determined that the facility failed to maintain an accurate log that reflects whether a patient seeking treatment was transferred, admitted, or discharged.

Findings include:

1. On 6/29/16, the L&D Loft Unit was toured, and the Antepartum Loft Daily Log [L&D Triage] was reviewed. Gaps in log entries were noted. Medical records of patients listed on the log were selected for review.

2. The log entries for Patients #33, #34, and #35 did not have a disposition specified in the "Patient Discharged/ Transferred To:" section.

a. Review of Medical Record #33 indicated Patient #33 was evaluated in the Loft and then admitted to L&D with a diagnosis of Pre-Eclampsia.

b. Review of Medical Record #34 indicated Patient #34 was evaluated in the Loft and then was discharged to home.

c. Review of Medical Record #35 indicated Patient #35 was evaluated in the Loft and was then discharged home.

3. The Log entry for Patient #35 did not indicate a time of arrival to the Loft.

a. Review of Medical Record #35 indicated the patient arrived to the unit on 6/13/16 at 1539.

Based on medical record review, review of facility documentation and staff interview, it was determined that the facility failed to ensure all patients are provided an appropriate medical screening exam without delay.

Findings include:

Reference: Facility Policy Title: EMTALA; On page 8 of 16, #4. On-call Physicians, #3. No Discrimination states, " No on-call physician shall discriminate in his or her response to a call or refuse to treat an individual on the basis of race, color, natural origin, ability to pay, method or source of payment, or any other reason unrelated to an individuals need for service or the availability of needed services in the facility, such as a prior diagnoses or any disability. "

Findings include:

1. A review of the Pediatric Neurologist on-call list for 6/2/16 and 6/3/16 was reviewed.

a. The list revealed that Staff #9 was on-call both days.

2. Documentation in Medical Record #1 indicated that Staff #9 did not evaluate or treat the patient related to a pending law suit the patient's mother has against the Pediatric Neurology Group that was on-call at this time.

a. The ED attending physician ordered a pediatric neurology consult for the patient. Staff #9 failed to provide the consult, which resulted in the patient having to be transferred, therefore causing a delay in treatment.

3. The above was confirmed by Staff #1.