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YORK HOSPITAL
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on document reviews and interviews, the hospital failed to ensure that Emergency Department policies were reviewed and updated for nine (9) of eighteen (18) policies reviewed.
Findings:
On 8/13/2025 at 11:00 AM, 18 Emergency Department policies were reviewed. Nine (9) policies have not been reviewed by the next review date listed at the top of each policy:
- Triage Guidelines in the York Emergency Department (last revised 11/2018, next review 3/2025)
- Administration of Intramuscular (IM) Methotrexate for the Treatment of Ectopic Pregnancy (last revised 1/2023, next review 3/2025)
- Dispensing of Medication: Emergency Department (last revised 4/2021, next review 3/2025)
- ED Care of the Patient with Suicidal/Homicidal Ideation (last revised 5/2018, next review 3/2025)
- Helicopter Transfer from York Hospital (last revised 7/2019, next review 3/2025)
- Legal Claim of Evidence for Emergency Department (last revised 1/2020, next review 3/2025)
- Management of Acute Ischemic Stroke (last revised 10/2022, next review 3/2025)
- On Call Physicians for EMTALA (last revised 9/2022, next review 3/2025)
- Review of Lab/Radiology Reports (last revised 1/2020, next review 3/2025)
On 8/13/2025 at 11:20 AM, the Chief Nursing Officer confirmed that there is no official policy on policy review, but that policies should be reviewed "every 3 years." At 1:05 PM, the Chief Nursing Officer confirmed that these eight (8) policies are past their review dates.
49750
Based on document reviews and interviews, the hospital failed to ensure that Emergency Department patient records included documentation of:
1. A physical exam for one (1) of ten (10) medical records reviewed. (ED #8)
2. A mental status for seven (7) of ten (10) medical records reviewed. (ED #1, ED #2, ED #3, ED #5, ED #6;,ED #8, and ED #9)
Findings:
1. On 8/13/2025, ED Pt. #8's medical record was reviewed with the Compliance Officer. The review revealed that a physical exam was not documented in the medical record.
The Compliance Officer confirmed this finding at that time.
2. On 8/13/2025, the medical records of ED #1, ED #2, ED #3, ED #5, ED #6, ED #8, and ED #9 were reviewed. The review revealed that a mental status exam was not documented in these medical records.
The Compliance Officer confirmed these findings at that time.