HospitalInspections.org

Based on interview and record and document review, the hospital failed to ensure an emergency room log for one out of 31 patients (Patient 1) was completed to ensure there was documentation of where the patient went, who took care of the patient and for how long, to determine the extent of care received in the facility Emergency Department (ED)

Findings:

During a telephone interview, on 10/19/16 at 8:26 a.m., Physician A stated on 9/18/16 he received a telephone call from the EMS (Emergency Medical System) transport team who informed him they were bringing in Patient 1 who was stable with "minor" facial trauma. Physician A stated Patient 1 arrived in 2 to 3 minutes, came in the ED on a gurney and Physician A observed Patient 1 had a jaw fracture, laceration and bruising around his eye. Physician A stated Patient 1 needed to go to the nearest trauma center because of the extent of his injuries. Physician A stated he saw Patient 1 less than 5 minutes and did a visual assessment and a "targeted medical screening exam" found the patient was stable and the patient was transferred by EMS to the trauma hospital.

During a record review and interview, on 10/20/16 at 9:20 a.m., the log titled ED Activity Log, dated 9/18/16, indicated Patient 1 arrived to the ED at 5:31 a.m. by ambulance. The reason for visit was listed as facial trauma, and diagnosis was facial trauma. The discharge time was listed as 2:39 p.m. on 9/18/16. There was no ED Physician or primary nurse listed. There was no admitting physician, discharge location or disposition listed. The Emergency Room (ER) Director stated the information regarding Patient 1, was entered the next day, in the electronic ED log. The ER Director stated the documented time out was wrong and stated the time out was supposed to be 5:37 a.m. The ER Director stated they made the decision to add Patient 1 to the log on 9/19/16 to provide some documentation about the case. The ER Director stated the disposition was not filled in as they were waiting for decision about the disposition of the patient. The ER Director stated they did not discharge Patient 1 and he did not elope and they did not know how to document that. The ER Director stated staff should have documented where the patient went.

Review of the facility policy, titled Cobra / EMTALA - Medical Screening, revised 9/14, indicated under "ADDENDUM" that the hospital was required to maintain a central log for those who come into the emergency room, or any location on the hospital property or premises seeking assistance. The disposition of each individual, whether he or she was transferred, admitted and treated, stabilized and transferred or discharged should be identified. The purpose of the central log was to track the care provided to each individual who comes to the hospital property or premises seeking care for a medical condition.