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ST. JOSEPH'S HOSPITAL AND MEDICAL CENTER
EMERGENCY ROOM LOG
Tag No.: A2405
Based on review of policies/procedures, documents, and staff and physician interviews, it was determined that the hospital failed to require the chronological log of emergency services included the patient's name, date, time, mode of arrival and disposition of the patient, including discharge, transfer, or admission, for 1 of 44 patients (Patient #1) presenting to the Emergency Department (ED). This deficient practice posed a threat to the quality of care when the hospital cannot track the patient and the services provided.
Findings include:
The hospital policy titled The Emergency Medical Treatment and Labor Act (EMTALA) #10039.1 (last reviewed 07/21/15) requires: "...Logs - Information about all patients with an emergency medical condition who present or arrive at a dedicated emergency department of the hospital must be recorded in an emergency services log...."
The hospital's Central EMTALA Log revealed that the hospital collects the following information on patients presenting to the ED: Arrival Time, Name, Account #, Date of Birth, Sex, Discharge Time, Reason for Visit, Chief Complaint, Mode of Arrival, and Discharge Disposition.
Patient #1 presented to the ED on 03/11/16 at 1023, complaining of chest pain, according to the Central EMTALA Log and the medical record. The patient was treated and released on 03/11/16 at 1023. Addendums in the medical record dated 03/23/16 and 03/29/16, revealed that Patient #1 returned to the ED for a 2nd visit on 03/11/16 at approximately 2200. ED Physician #1, ED Social Worker #18, and the ED Charge Nurse (CN) #7 documented that they spoke with the patient in the ambulance regarding the patient's new complaint of anxiety related to concerns for a timely delivery of durable medical equipment (DME) to the residence.
The VP of Care Management and the Senior Director of Hospital Operations both confirmed during interviews conducted on 04/08/16, that the hospital's Central EMTALA Log confirmed Patient #1's arrival on 03/11/16 at 1023 but did not include the patient's return visit to the ED on 03/11/16 at approximately 2200.