HospitalInspections.org

Based on record review of the facility Central Log, policy for maintaining the log, record review of 21 emergency patient records and staff interview the facility failed to ensure a Central Log was completed to document the care provided to each individual who came to the hospital seeking emergency treatment. 1 (Patient 8) of 21 sampled emergency patients failed to be entered in the Central log at all. 2 (Patient 13 and 16) of 21 sampled patients were entered in the log but had missing information, An additional 18 non sampled patient entries had either incomplete or non-chronological log entries when logs were reviewed since 4/1/15. The facility sees on average 22 patients per month. Failure to maintain the Central Log has the potential to affect all patients coming to the Emergency Department (ED) for treatment. The Central Log provides the facility information that can be used to identify/track and trend opportunities to improve the quality of care for ED patients. Findings are:

A. Upon request at entrance 10/28/15 at 1:45 PM the Director of Nursing (DON) provided the hardbound Central Log book titled "Emergency Room Register." The log entry includes the following categories: Date; Time; Name; Address; Age; Gender; Nurse or Physician's Assistant; Physician; Nature of Injury/Illness: Emergency;Non-emergency; Treatment refused; Did Not Treat; Reason; Admitted; Stabilized/Transferred; Name of Receiving Facility; Treated & Discharged; Time; Instructions Provided/Explained. The log book was reviewed for entries from 4/1/15 through 10/28/15.
Record review of the log entry page starting with 4/25/15 and ending with 5/4/15 revealed the log identifies 17 patients who came to the emergency room. 7 entries lacked identification of the Nature of their Injury Illness. 14 entries lacked the reason for the visit. 3 entries lacked any identification of the patient's disposition (discharge, transfer, admitted). ED medical record review on 10/29/15 revealed Patient 16 was seen in the ED on 4/25/15 at 3:45 PM, treated and discharged home. The log entry does not contain any information related to disposition for Patient 16. ED medical record review on 10/29/15 revealed Patient 13 was seen in the ED on 5/4/15 at 9:19 AM. The log entry for Patient 13 lacks the nature of the injury/illness or information regarding disposition. The entry is also out of chronological order appearing after an entry dated 5/17/15. 6 of the 17 entries on the page in the log are out of chronological order.
Record review of the log entry page starting with 8/15/15 and ending with 9/6/15 identifies 19 entries with 1 of those 19 entries out of chronological order. The entry for 8/17/15 appears after 8/19/15.
Record review of the log entry page starting with 9/7/15 and ending with 9/26/15 identifies 19 entries with 1 of 19 entries out of chronological order. Entry for a patient seen on 9/19/15 appears after an entry for 9/21/15. 2 entries lacked identification of their disposition. Record review on 10/29/15 of the ED record for Patient #8 revealed the patient was seen in the ED on 9/21/15 at 3:33 PM. The log contains no information that Patient 8 had even been seen in the ED on 9/21/15.
Record review of the log for 9/26 to 10/11/15 identifies 20 entries with 2 of 20 entries out of chronological order. An entry on 9/13/15 appears between an entry for 10/7 and 10/8/15. An entry for 10/5/15 appears after 10/6/15.

B. Interview with the DON on 10/28/15 at 2:40 PM confirmed staff nurses are not always getting the central log completed and not getting information in chronological order. The DON revealed that when charts are reviewed if one is found that was not entered it is added at that time. The DON confirmed entering the 9/13/15 entry between the 10/7 and 10/8/15 as identified in Example A. The DON also confirmed Patient 8 who was seen in the ED on 9/21/15 was not entered in the log at all.
An additional interview with the DON on 10/30/15 at 1:30 PM confirmed the Central log policy needs to be updated with the expectation that all patients whether seen or not must be logged. The expectation is that there will be "no blanks or incompletion". The DON stated the log "must be complete" and "needs to be chronological".

C. Record review of facility policy titled "Emergency/Transfer Policy/EMTALA [Emergency Medical Treatment and Labor Act]" last revised 7/2012 states "All individuals that present to the ED, and for whom examination or treatment is requested, shall be recorded in the ED Log book. The log will include date, patient name, treating physician, if the patient refused treatment, was refused treatment, if they were stabilized & transferred, admitted or discharged".