HospitalInspections.org

Based on medical record (MR) review, document review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, the hospital failed to enter a patient on their emergency department (ED) Central Log and the hospital did not provide a medical screening exam (MSE) to a patient (Patient #1) who presented to the ED for evaluation to determine if an emergency medical condition (EMC) existed. This could lead to untoward patient outcomes. Please reference findings at Tag 2405 and Tag 2406.

Based on document review and interview, the hospital did not ensure all individuals presenting to the Emergency Department (ED) for evaluation were entered into the ED Central Log. This could cause patients to not receive the required treatment.

Findings include:

-- Review of hospital policy and procedure (P&P) titled "EMTALA Medical Screening Exam (MSE)", last revised 9/26/2022, revealed "when an individual comes to ACH campus and a request is made on the individual's behalf for medical examination or treatment, ACH must provide for an appropriate MSE within the capability of the emergency department ... " It defined the ED Central Registration Log as a "log which the hospital is required to maintain on each individual who comes to its emergency care unit (ED) or any location on hospital property or premises seeking assistance and the disposition of each individual, whether he/she refused treatment, was refused treatment, left without being seen, or whether he/she was transferred, admitted and treated, stabilized and transferred, or discharged. The purpose of the log is to track the care provided to each individual who comes to the hospital property or premises seeking care for an emergency medical condition."

-- Review of the EMS call log revealed there were two entries on 2/22/2023 (misdated 2/21 but verified to have been on 2/22/23 by ED Manager) which corresponded to a patient's (Patient #1's) arrival by ambulance at 12:31 am and again 4:45 am.

-- Per review of the ED Central Log, there was no entry for Patient #1 at 4:45 am. There was also no MR regarding Patient #1's second visit on 2/22/2023.

-- Per interview of Staff A, ED Nurse Manager, on 6/9/2023 at 10:05 am, there was a complaint from EMS regarding an employee (identified as Staff B, Registered Nurse) refusing to allow Patient #1 into the ED. He/she indicated that an internal investigation was conducted and it was determined that Staff B did not follow hospital protocol and he/she confirmed Patient #1 did not get entered into the ED Central Log when she presented for the second time on 2/22/2023 at around 4:45 am.

-- During interview of Staff C, Vice President of Quality Management, on 6/9/2023 at 2:30 pm, he/she acknowledged the above findings.

Based on document review and interview, the facility did not ensure that all individuals presenting to the Emergency Department (ED) were provided with an appropriate medical screening examination (MSE). Specifically, no evidence was found to indicate that Patient #1 received a MSE when she presented (for a second time) to the ED on 2/22/2023 at approximately 4:45 am. This could result in a patient not being provided the appropriate treatment.

Findings include:

-- Review of hospital's policy and procedure (P&P) titled "EMTALA Medical Screening Exam (MSE)", last revised 9/26/2022, revealed "when an individual comes to the Auburn Community Hospital (ACH) campus and a request is made on the individual's behalf for medical examination or treatment, ACH must provide for an appropriate MSE within the capability of the emergency department (ED) ... to determine whether or not an emergency medical condition (EMC) exists ..."

-- Review of the EMS call log revealed there were two entries on 2/22/2023 (misdated 2/21 but verified to have been on 2/22/23 by ED Manager, Staff A) which corresponded to Patient #1's arrival by ambulance at 12:31 am and again 4:45 am.

-- Review of the ED Central Log for 2/22/2023 revealed no evidence that Patient #1 was entered in the log when she presented via EMS (for the second time) on 2/22/2023 at approximately 4:45 am.

-- Per interview of Staff A, ED Nurse Manager, 6/9/2023 at 10:05 am, a complaint was received from EMS regarding a registered nurse (RN) (identified as Staff B) refusing to allow Patient #1 into the ED. He/she indicated that an investigation was conducted and it was determined that Staff B did not follow hospital protocol. He/she confirmed that no medical record was created for Patient #1's visit (on 2/22/23 at approximately 4:45 am) and no MSE was performed.

-- Per interview of Staff C, Vice President of Quality Management on 6/9/2023 at 2:30 pm, he/she acknowledged the above findings.