HospitalInspections.org

Based on review of the hospital's Emergency Department (ED) Central Log, review of the hospital's emergency department policies and procedures, and interview, the hospital failed to ensure its central log had the patient's discharge disposition documented for 18 random patients who presented to the hospital's emergency department requesting services. (Random Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,13,14,15,16,17, and 18)

The findings are:

The facility's Corporate Policies and Procedures Manual EMTALA policies titled "EMTALA .004- CENTRAL LOG RELATED TO ED VISITS" Date approved: 3/7/2017, Effective Date: 4/27/2017 was reviewed. The Policy revealed in part, Purpose: To require that a hospital with an Emergency Department track the care provided to each individual seeking care in a Dedicated Emergency Departmetn("DED") for a medical condition or seeking care in areas on hospital property other than a DED for what may be an Emergency Medical Condition ("EMC"), as required by the Emergency Medical Treatment and Labor Act...Policy: ...hospital that provides emergency services must maintain a Central Log that contains information on each individual who "comes tot he emergency department" seeking assistance, including, but not limited, the individual's name and whether the individual refused treatment , was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged."

On 04/10/18 from 3:30 p.m. to 4:15 p.m., review of the emergency department's central log from October 2017 through December 29, 2018 revealed 18 random patients did not have their discharge disposition documented on the emergency department's central log.

Random Patient 1 presented to the emergency department on 10/4/17 at 6:30 p.m. with a chief complaint of a need for a psychiatric evaluation. There was no discharge disposition documented on the central log.

Random Patient 2 presented to the emergency department on 10/5/17 at 10:22 a.m. with a chief complaint of adult illness. There was no discharge disposition documented on the central log.

Random Patient 3 presented to the emergency department on 10/8/17 at 2:07 p.m. with a chief complaint of nausea/vomiting. There was no discharge disposition documented on the central log.

Random Patient 4 presented to the emergency ER on 10/8/17 at 9:39 a.m. for a chief complaint of upper extremity pain. There was no documentation recorded for the disposition of the patient on discharge.

Random Patient 5 presented to the emergency department on 10/11/17 at 12:23 p.m. with a chief complaint of male Urogenital. There was no discharge disposition recorded on the central log.

Random Patient 6 presented to the emergency department on 10/13/17 at 10:03 p.m. with a chief complaint of neck injury. There was no discharge disposition recorded on the central log.

Random Patient 7 presented to the emergency department on 10/21/17 at 1:43 a.m. with a chief complaint of nausea/vomiting. There was no discharge disposition recorded on the central log.

Random Patient 8 presented to the emergency department on 10/25/17 at 12:22 p.m. with a chief complaint of cold symptoms. There was no discharge disposition recorded on the central log.

Random Patient 9 presented to the emergency department on 10/29/17 at 6:45 p.m. with a chief complaint of nausea/vomiting. There was no discharge disposition recorded on the central log.

Random Patient 10 presented to the emergency department on 10/31/17 at 7:37 p.m. with a chief complaint of motor vehicle crash. There was no discharge disposition recorded on the central log.

Random Patient 11 presented to the emergency department on 11/6/17 at 1:55 p.m. with a chief complaint of head injury, adult. There was no discharge disposition recorded on the central log.

Random Patient 12 presented to the emergency department on 11/13/17 at 6:17 p.m. with a chief complaint of need for a psychiatric evaluation. There was no discharge disposition recorded on the central log.

Random Patient 13 presented to the emergency department on 11/16/17 at 8:04 p.m. with a chief complaint of fever, pediatric. There was no discharge disposition documented on the central log.

Random Patient 14 presented to the emergency department on 11/19/17 at 11:33 a.m. with a chief complaint of hip pain. There was no discharge disposition documented on the central log.

Random Patient 15 presented to the emergency department on 11/25/17 at 2:35 p.m. with a chief complaint of chest pain. There was no discharge disposition documented on the central log.

Random Patient 16 presented to the emergency department on 12/7/17 at 3:39 p.m. with a chief complaint of substance dependency. There was no discharge disposition documented on the central log.

Random Patient 17 presented to the emergency department on 12/28/17 at 6:58 p.m. with a chief complaint of chest pain. There was no discharge disposition documented on the central log.

Random Patient 18 presented to the emergency department on 12/29/17 at 12:56 p.m. with a chief complaint of Dyspnea. There was no discharge disposition documented on the central log.

Findings were verified with Emergency Department Director at 4:30 p.m.