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Based on interview and record review, the facility failed to ensure the central emergency department (ED) log accurately tracked 3 of 21 patients (P1, P16, P21) who presented to the ED seeking care for an emergency medical condition.

Findings include:

During the entrance conference on 6/3/25, at 8:46 a.m., the previous six months of ED logs were requested.

On 6/3/25, at 11:07 a.m., the requested ED logs were provided via email. The logs contained daily sheets labeled Daily Census Sheet and identified an Emergency Room Log section that indicated columns for patient name, time of presentation, chief complaint, time of discharge, disposition, and stability at discharge. These columns contained hand-written entries of patients and associated information.

A Common Entry Point (CEP) report, submitted to the State agency (SA) on 3/31/25, identified an unknown female patient presented to the ED on 3/28/25, with left lower abdominal pain after a potential miscarriage two weeks prior.

A Daily Census Sheet, dated 3/28/25, identified seven patients who presented to the ED that day; however, a patient representing the CEP report patient details was not listed.

An Emergency Department Management Daily Summary report, requested from the facility to identify all patients who were registered in the ED on 3/28/25, verified a patient, not listed on the Daily Census Sheet, arrived on 3/28/25 at 8:29 a.m., for abdominal pain. She discharged home on 3/28/25 at 9:35 a.m. The CEP patient, based on review of this form and medical record review, was determined to be P1.

During an observation on 6/3/25, at approximately 11:00 a.m., the 6/3/25 Daily Census sheet was observed in a three-ring binder located at the hospital's nurses station. The ED log lacked entries. At that time, one patient was present in the ED who presented at approximately 9:57 a.m.

During an abbreviated medical record review, on 6/4/25, the following two additional ED Log inconsistencies were identified:

-P21's medical record identified P21 presented to the ED on 4/21/25.

-Daily Census sheets, dated 4/20/25 and 4/21/25, both identified, at 5:33 a.m., P21 presented to the ED for a throat lump. At 7:10 a.m., P21 discharged home in stable condition. P21 was incorrectly entered on the 4/20/25 ED log.

-P16's medical record verified P16 presented to the ED on 5/16/25.

-The Daily Census sheet, dated 5/16/25, lacked information P16 presented that day, despite his presentation.

-A Daily Census sheet, dated 5/17/25, identified P16 presented to the ED on 5/16/25 at 11:51 p.m. for intoxication. On 5/17/25, at 9:20 a.m., P16 discharged home in stable condition.

When interviewed on 6/3/25, at 11:08 a.m., health unit coordinator (HUC)-A stated she or the nurse entered each patient onto the ED log the day they presented. The timeframe for this entry varied.

During an interview on 6/3/25, at 11:42 a.m., registered nurse (RN)-A (the RN identified to be P1's nurse based on chart review) stated all patients were expected to be entered onto the ED log when the patient presented to the ED. RN-A explained P1's situation potentially sounded familiar; however, she lacked detailed remembrance.

When interviewed on 6/3/25, at 12:55 p.m., RN-B stated generally when the patient was discharged all the paperwork from the ED encounter was brought to the main hospital's nurses' station and the patient was then added at that time to the ED log. She explained every patient that presented was expected to be entered onto the log for that day of presentation.

On 6/3/25, at 1:35 p.m., both the assistant administrator (AA)-A and the administrator were interviewed together. They stated the ED log was a nursing process, and it was their understanding that each patient that presented to the ED was required to be entered onto this form the day they presented. Once completed, the forms were sent to admissions where they were audited to ensure accuracy. Both stated expectations that the logs should have accurate information.

When interviewed on 6/3/25, at 1:52 p.m., patient registrar (PR)-A stated the ED logs were completed by the nurses. The day of the week determined when she received these sheets. If a patient presented on a Friday [the day P1 presented], or during the weekend, she typically was able to audit these sheets for accuracy the following Monday or Tuesday. She explained that during these audits, the information was not always accurate which prompted director of nursing (DON) collaboration to determine accuracy. PR-A denied any specific evidence for these audits as this was a standard workflow process. When P1 presented to the ED, PR-A was out on medical leave and PR-A did not return until 4/4/26. During this time, it was her understanding others in her department were expected to complete this job duty. PR-A explained she expected P1's missed entry to have been caught at that time.

During an interview on 6/3/25, at 2:33 p.m., the revenue cycle director (RCD)-A stated she covered for PR-A during PR-A's medical leave. She explained, during that time, the department staffing was decreased by approximately half, and they underwent a financial audit. She acknowledged P1's entry was missed, and this appeared to be an oversight during that time. RCD-A expected all patients who presented to the ED were accounted for on the appropriate ED log; however, she did question why handwritten ED logs were used when their computer system had the capacity to run reports with the required information.

When interviewed on 6/4/25, at 1:41 p.m., P1's ED medical doctor (MD)-A stated he was unfamiliar with the ED log processes and was not aware the nurses completed such a form.

An EMTALA (Emergency Medical Treatment and Labor Act) policy, dated 2/10/25, directed all individuals who presented for evaluation and treatment must be entered into the Central Log. The policy lacked additional details related to the Central Log process.