HospitalInspections.org

Based on record review and interview, the hospital failed to maintain an accurate and complete Emergency Department Central (patient) Log on each individual who came to the Emergency Department as evidenced by failing to document in the central log a patient who presented with leg and left side pain after falling.

Findings:

Review of the Emergency Room's Policy titled Transfer Policy- EMTALA Reference Number A-8, revealed in part, The Emergency Department shall maintain a Central Log documenting the following information:
a. Each individual presenting to the ED for assistance
b. If the individual refused treatment
c. If the individual was refused treatment
d. If the individual was transferred, admitted and treated, stabilized and transferred of discharged.

On 7/12/18 a review of the Central Log between the dates 6/17/18 and 6/30/18 failed to reveal Patient #2 was registered as a patient; therefore, no patient record was available for review.

Review of the Hospital's Grievance Log revealed Patient #2 had filed a grievance about an Emergency Department visit at the hospital on 6/26/18.

In an interview on 7/12/18 at 2:25 p.m. with S1RN, he stated Patient #2 came in to Emergency Department complaining of pain to her left side rib. He verified she was not entered into the Central Log.

In an interview on 7/12/18 at 3:00 p.m. S2Dr stated he remembered Patient #2 coming to the Emergency Department on 6/26/18. S2DR said he never examined Patient #2 because she was afraid her insurance would not cover the charges. He verified if she presented to the Emergency Department with an emergency she should have been added to the Central Log.

In an interview on 7/12/18 at 4:00 p.m. S3RegClk stated Patient #2 came in to the Emergency Department crying and said she fell down and she wanted to check in to the Emergency Department. S3RegClk said Patient #2 complained of pain to her leg and left side rib pain and she had x-rays earlier that day but she did not have the results. S3RegClk stated she did receive Patient #2's insurance and identification cards, which is the needed information to register her in the Central Log. S3RegClk verified she did not register Patient #2 in the Central Log.

In an interview on 7/13/18 at 7:30 a.m. S4RN admits Patient #2 stated she had x-rays done with her primary care physician and was having leg and rib pain. S4RN stated she told S2Dr that Patient #2 was in pain but did not want to check in due to insurance possibly not covering the bill. S4RN admits S2Dr never saw Patient #2. S4RN verified a patient should be registered if they presented to the ED with a complaint of pain and gave their insurance cards to the Registration Clerk. Also, if the patient left without being triaged, staff should have documented the patient left without being triaged.

In an interview on 7/13/18 at 8:00 a.m. S5DirAdm stated S3RegClk was given Patient #2's insurance cards and ID; therefore, S3RegClk should have registered Patient #2 in the Central Log. S5DirAdm said Patient #2 was not registered so there was no information in the computer from the day of her emergency room visit. S5DirAdm said the Registration Clerks had a hand written log where they could document the disposition such as when a patient was not registered.

Based on record review and interview, the hospital failed to ensure that a medical screening examination was provided to a patient who presented to the hospital's Emergency Department seeking treatment for pain to her leg and left side after falling. This was noted for 1 (#2) of 25 (#1-#25) sampled patients.

Findings:

On 7/12/18 a review of the ED Central Log between the dates 6/17/18 and 6/30/18 failed to reveal Patient #2 was registered as a patient; therefore, no patient record was available for review.

In an interview on 7/12/18 at 2:25 p.m. S1RN stated Patient #2 came in to ED complaining of pain to left side rib and had an x-ray the day before. S1RN confirmed Patient #2 had a medical condition.

In an interview on 7/13/18 at 7:30 a.m., S4RN said she was the triage nurse in the ED the day Patient #2 came to the ED. She stated the admit clerk called her in the emergency department and stated Patient #2 wanted to speak with the nurse. S4RN stated Patient #2 told her she had x-rays taken by her MD due to leg and rib pain, but did not want to check in due to insurance. S4RN said she did not ask Patient #2 to rate her pain. S4RN said Patient #2 asked her if the ED doctor would look at her x-rays. S4RN states she told Patient #2 the Emergency Department MD may or may not review Patient #2's x-rays, but she would ask. S4RN said she did not comple an assessment on Patient #2. S4RN said S2Dr was able to review Patient #2's x-rays then told S4RN the x-rays were fine. S4RN stated S2Dr did not make any recommendations such as over the counter medications or any type of follow up appointment. S4RN then stated she asked Patient #2 if she had anything at home that she could take for the pain until she followed up with her primary care physician. S4RN stated S2Dr never saw the patient.

In an interview on 7/12/18 at 4:00 p.m. S3RegClk stated Patient #2 came in crying and said she had fallen down. She said Patient #2 said she wanted to check in to the ED and complained of pain to her leg and left side rib pain. She said Patient #2 said she had x-rays earlier that day but she did not have the results. She said Patient #2 did not know if the insurance would pay and had been out of work for 6 months. S3RegClk said she then called S4RN who was the triage nurse. S3RegClk stated she did receive the patient's insurance and identification. She said she asked Patient #2 to have a seat while she checked her in and then Patient #2 could sign the paperwork. S3RegClk said S4RN came to triage and Patient #2 told S4RN she was hurting and had leg and left side pain and had x-rays but had not received the results. She said Patient #2 was like "climbing up the walls." Patient #2 stated if the x-rays were normal she could wait and go to her doctor later. She said then S4RN went and talked with S2Dr. She said Patient #2 then stated "If my results come back normal I could just go to my doctor." She said Patient #2 then said, "I just don't feel right and something is wrong." S4RN came back and told Patient #2 they didn't see anything abnormal on the x-ray. Patient #2 then left the emergency department.

In an interview on 7/12/18 at 3:00 p.m. S2Dr stated he remembered Patient #2 coming to receive the results of her x-ray. He said he was not made aware of any complaints from the patient. S2Dr further stated patients may come to ED for test results but it was not common. S2Dr said he did not speak with Patient #2. S2Dr admitted he pulled up the x-rays on the computer and looked at the x-ray. He told S4RN there was no unusual findings on the x-ray. S2Dr denied S4RN stating Patient #2 had any issues or complaints of pain. S2Dr said if Patient #2 would have complained she would have been seen in the ED as a patient. S2Dr stated he specifically asked S4RN if Patient #2 had any complaints.