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ASCENSION ST JOHN MEDICAL CENTER

1923 SOUTH UTICA AVENUE

TULSA, OK 74104

EMERGENCY ROOM LOG

Tag No.: A2405

Based on record review and interview, the hospital failed to enter into the Emergency Department (ED) log the disposition for 28 entries for the period from 01/01/19 through 02/11/19.

This failed practice resulted in the hospital's inability to track the disposition of all individuals presenting to the ED seeking emergency medical attention as defined by EMTALA regulations.

Findings:

Review of hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA), revised 01/17" showed all patients who entered the ED "seeking treatment" would be entered into the log ...the log would contain whether the patient was transferred, admitted, transferred or discharged.

Review of the ED log from 01/01/19 through 02/11/19 showed 28 entries with no evidence of documentation of the patient's disposition.
· On 01/02/19 one ED log entry had no disposition identified.
· On 01/10/19 two ED log entries had no disposition identified.
· On 01/15/19 one ED log entry had no disposition identified.
· On 01/30/19 one ED log entry had no disposition identified.
· On 01/31/19 two ED log entries had no disposition identified.
· On 02/04/19 two ED log entries had no disposition identified.
· On 02/05/19 two ED log entries had no disposition identified.
· On 02/06/19 two ED log entries had no disposition identified.
· On 02/07/19 12 ED log entries had no disposition identified.
· On 02/08/19 one ED log entry had no disposition identified.
· On 02/09/19 one ED log entry had no disposition identified.
· On 02/10/19 one ED log entry had no disposition identified.

On 02/12/19 at 9:37 am, Staff A stated a rapid triage form was used to initially triage the patient at the time of registration and determine a triage level. Staff A stated the information obtained from the rapid triage form such as the patient's name, age, date, arrival time, and triage level was extracted to form the ED log. Staff A stated the patient's disposition would be obtained during the "check-out" process at the time the patient was discharged, transferred or admitted.