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Based on interview and document review the facility failed to establish and maintain an Emergency Department (ED) log for every person who comes to the ED as reflected in 1 of 1 person.

On 4/5/2011 at 9:00 AM in the conference room an interview with the Director of Quality Management (DQM) indicated a patient had arrived in the ED at 11:57 PM. The person signed a triage ticket. He told the triage nurse he was suicidal and was going to Glenwood (Glen Oaks Hospital). He told the triage nurse he needed a medical clearance. The patient and his wife asked questions of the triage nurse regarding expediting the process. The Triage nurse called the physician on duty who came and talked with the family. After speaking with the physician the patient and his wife decided to leave the ED and drive to another hospital closer to Glen Oaks for the medical clearance.

Further review revealed no documentation of the patients visit existed other than the triage ticket. The patient was not found on the ED log. There was no triage nurses note or physician progress note indicating the patient had chosen to leave.

Based on interview and document review the facility failed to provide a Medical Screening Exam for 1 of 1 person who came to the Emergency Department.


On 4/5/2011 at 11:00 AM in the conference room an interview with the DQM revealed the following; When the patient began questioning the procedure for a medical screening and clearance the physician told the patient the hospital would not transfer him by ambulance until morning because when only two (2) crews were scheduled at night no non-emergency transports were done. The physician went on to tell the Pt/wife no sheriff's deputy would make the transport at night either. To facilitate the transport the physician suggested they drive to a closer hospital to get the medical clearance. The physician offered to contact a fellow ED physician at the a hospital very near where the Pt wanted to be admitted and secure approval for the medical clearance. The Pt/wife agreed and left to drive to the nearer hospital.

Further review of medical records revealed the patient was not given a medical screening even though the patient was lucid, and articulate concerning his desire to commit suicide and how he would carry it out. (He had a plan) The medical emergency was not assessed to determine if the patient was stable to leave with is wife and a friend to drive to the next hospital.

There was no medical record for this patient. The physician did not document his conversation with the Pt/wife. The physician did not document his conversation with the ED physician at the nearer hospital. There was no medical record documentation on this Pt other than the triage ticket which records the following: Arrival time as 1157, date 3/27/2011, Patient's name, Dr, Reason for visit "suicidal thoughts, I'm going to Greenville I need medical clearance"

The patient arrived in the ED. He told the triage nurse what he needed. He was never admitted to the ED for a Medical Screening Exam or stabilization. There was no documentation he left Against Medical Advice. There was no documentation.

Based on interview and document review the facility failed to provide acceptable documentation for 1 of 1 transferring patient.

On 4/7/2011 at 1:00 an interview with the Administrator of the receiving hospital revealed that when his ED nurse had called for records she was told "well the patient was never really a patient here". There were no records.

Further review of the records from the transferring hospital revealed there was no documentation for the patient having been in their ED other than the triage ticket. There was no documentation of the phone call made by the transferring physician. There was no documentation the patient had changed his mind and had decided to travel to another hospital for the screening.

On 4/5/2011 at 1:00 PM the ED director confirmed there were no records to forward for the patient.

A review of policy Emergency Department Plan of Care I. SCOPE OF SERVICE Patient's with certain conditions may need transferred to other facilities after initial evaluation and appropriate treatment is provided Examples include Psychiatric conditions (suicide).

A review of Administrative Policy & Procedure Emergency Treatment and Transfers: All patients presenting to the facility will receive a medical screening exam to determine if an emergency medical condition exists. Patient's determined to have an emergency medical conditions will be stabilized within the capability of the facility. If the patient's medical condition requires a higher level of care or if the patient requests, the patient will be stabilized to the extent of the facilities capability and transferred to an appropriate accepting facility as determined by the transferring physician.

A review of Administrative Policy and Procedure Emergency Treatment Emergency Transfers-Definition
5. The term "emergency medical condition" means A. 1) Placing the health of the individual in serious jeopardy, 2) Serious impairment of bodily functions. V. The facility will provide a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient to the receiving physician and receiving hospital with the patient.

The facility did not follow it's policy to provide all patients who present to the Emergency Department with a medical screening to determine if a medical emergency condition exists. The facility did not establish if the patient's condition was stable. The facility did not provide a copy of the patient record to the receiving facility.