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Based on reviews of medical records, Grady Memorial Hospital Medical Staff Rules and Regulations, and policies and procedures and interviews the facility failed to ensure that when an individual " comes to the emergency department " an appropriate medical screening examination was provided that was with in the capability of hospital ' s emergency department, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (Patient #1) of twenty (20) sampled patients. This practice could cause potential harm and delay and delay in treatment for a medical emergency. Refer to findings in Tag 2406.

Based on reviews of medical records, Emergency room Log, and interviews, the facility failed to ensure that a central log was maintained for each individual seeking assistance and whether he/she refused treatment, was refused treatment, or whether he/she was transferred, and admitted and treated, stabilized and transferred, or discharged for one (1) patient (#1) of twenty (20) sampled patients who presented to the Emergency Department (ED). Additionally, the facility failed to develop policies and procedures related to maintaining an EMTALA Emergency room log.

Findings include:

Review of patient #1 medical record revealed the 40 year old patient came to the facility on public transportation. The patient was expected to Emergency Department time at 5:53 p.m. on 11/6/2011. The patient was entered into the electronic system by Patient Access Representative #3. The patient received a medical record number that contained the name, date, date of birth, age and chief complaint (leg/hip and bilateral shoulder pain).


Review of the Emergency Room Log for 11/6/2011 had not listed patient #1. In addition it was confirmed by the by the Patient Safety/Accreditation Officer that the patient was not listed on the ED log.


Interview was conducted on 1/13/2015 at 1:20 p.m., with the Patient Access Representative #2 of the Emergency Department (ED). He/She stated that every patient entering the ED will be placed in the system and an emergency room log can be generated.

Review of the medical record for Patient #1 verified that on 11/6/2011 he/she (Patient #1) presented to Grady Memorial Hospital seeking assistance, and Patient#1 was not listed on the ED Log.

Review of the facilities Policies and Procedures as it is related to ED central log failed to reveal the facility had a policy that addressed Emergency Department Log.

Based on reviews of medical records, Grady Memorial Hospital Medical Staff Rules and Regulations, and policies and procedures and interviews the facility failed to ensure that when an individual " comes to the emergency department " an appropriate medical screening examination was provided that was with in the capability of hospital ' s emergency department, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for 1 (Patient #1) of twenty (20) sampled patients. This practice could cause potential harm and delay and delay in treatment for a medical emergency.
Findings Include:

Review of the Grady Medical Staff Rules and Regulations dated February 6, 2012 revealed: All patients presenting to the Emergence Department would receive a medical screening exam. Medical screening exams would be performed by a physician or physician extender (physician assistant or nurse practitioner).

Review of the facility policy, entitled, "Absent Without Leave/Elopement/Walk Away and AMA" Origin 7/1997, revised 06/2010 indicated in procedures if a patient was in the ED and left the area. Staff is to call the patient three (3) times and note in the medical record/electronic system that the patient Does Not Answer ( DNA) and document each attempt date and time ... " 3. Document on the medical record that the patient was told not leave the area. "

Review of patient #1 medical record revealed the 40 year old patient came to the facility on public transportation. Patient #1 was expected to Emergency Department time was at 5:53 p.m. on 11/6/2011. The patient was entered into the electronic system by the Patient Access Representative #3. A medical record was generated for the patient that contained a medical record number, the patient ' s name, date of birth, age, " Arrival complaint " g/f (ground/fall) lt (left) leg/hip and bilateral shoulder pain " and the date the patient presented to the ED. Further review of the electronic medical record revealed in part, Chief compliant -none; " ED treatment team-none; Dictations-None; ED diagnosis-none; ED disposition: None ...Trauma Mechanism of Injury -none; Labs-none; Imaging results- none; EKG results- none; ...ED medication orders- none; ...Discharge orders: None; ...Medical History: none; Surgical History-none; ED vitals from to: none; ED events: 11/6/11 1753 (5:53 p.m.) Pt expected in ED; D/C instructions: none; ...Routing History- there are no sent or routing communication with this encounter. " There was no documentation in the electronic medical record to indicate that on 11/6/2011 patient #1 was noted to have been called 3 times and that Patient #1 did not answer and there was no documentation of the date and time of attempts to call Patient #1, as stated in the hospital ' s policy. Additionally, there was no documentation in the medical record on 11/6/2011 to indicate that patient #1 was told to " not leave the area " as stated in the facility ' s policy and procedure. There was no documentation in the medical to indicate that on 11/6/2011 patient #1 received a medical screening examination by a physician or physician extender as stated in Grady ' s Medical staff Rules and Regulations.

Interview was conducted with the Patient Access Representative #1 on 1/13/15 at 1:00 p.m. in the conference room. The representative stated the patients who walk in the ED would present themselves to nurse in the front area of the ER. They signed in and were asked for their social security, date of birth, last and first name reason for visit, the information was placed in the system. The patient received by the registrar a name band and asked to have a seat in the waiting room. Then the nurse/technician called the patient about three (3) times and documented it in the medical record. The representative reported the nurse let the registration representative know when the patient had left. The representative would not do anything else after the nurse takes the patient out of the system.
Interview was conducted with the ED charge nurse on 1/13/15 at 1:45 p.m. The nurse explained if the patient was checked in the ED and not yet triaged or screened, the patient was called once every 30 minutes for three (3) times and if no response it was document in the medical record that the patient Does Not Answer ( DNA) and the nurse then discharged the patient in the system.

An interview was conducted on 1/13/15 at 3:15 p.m. with the Clinical Assistant who explained that patients who Left Without Being Seen ( LWBS) a note was made in the comment section of the medical record. You could see the patient was called at least three (3) times, usually 15 -30 minutes apart. The Assistant reported in review of medical record ( Patient #1) had not revealed the patient Left Without Being Seen (LWBS), AWOL, Eloped, Walk Away, Left Against Medical Advice (AMA) or was documented as the patient Does Not Answer (DNA).

The facility failed to ensure that their policy and procedures were followed as evidenced by failing to ensure that a medical screening examination was provided that was within the capability of the hospital for patient # 1 on 11/6/2011.