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Based on interview and record review, facility failed to maintain an accurate central log of patients seeking care for an emergency medical condition, including whether patients refused treatment, were admitted and treated, stabilized and transferred, or discharged (known collectively as patient disposition) when:

1. 22 of 75 log entries reviewed did not include patients' disposition (Patients 23-44),

2. One of the ten patients (Patients 45) who received emergency care on 10/5/24 and two of eleven patients (Patient 46 and Patient 47) who received emergency care on 2/8/25 were not listed on the central log,

3. Two patients (Patient 48 and Patient 49) presenting for outpatient services (laboratory draws and prescribed on-going care) on 10/5/24 and one patient (Patient 50) presenting for outpatient services on 2/10/25 were listed in the central log.

These failures resulted in the inability to accurately track the emergency care delivered.

Findings:

During a concurrent interview and record review of the Emergency Department (ED) Central Log (CL) with Emergency and Acute Care Nurse Manager (NM), on 3/5/25 at 10:50 a.m., NM confirmed the paper log book located in the ED was the CL and was missing disposition entries on log pages 24, 59, and 77. NM stated ED techs were responsible for completing log entries and had failed to do so. NM stated the disposition information would be in individual patient electronic records. NM stated the Quality and Compliance Lead (QCL) could create and provide an electronic record for the dates requested for review, which were 10/5/24 and 2/8/25.

During a concurrent interview and record review of the CL and electronic health record report (eHRR) of ED visits, with Chief Nursing Officer (CNO), NM, and QCL on 3/6/25 at 2:05 p.m., QCL stated the eHRR was comleted on 3/6/25 at 11 a.m. (24 hours after surveyor request.) QCL stated eHRR had not been created prior to surveyors' arrival and was not readily available on 3/5/25.

In a continued interview and record review, the two records were compared. The eHRR indicated Patient 45 received emergency care on 10/5/24, and Patient 46 and Patient 47 received emergency care on 2/8/25. CNO stated the eHRR was the most accurate record of emergency care delivered. NM confirmed patients received emergency care on those dates and the CL did not record the visits, and stated, "The department must have been busy those days."

In a continued interview and record review of the CL and eHRR, NM and QCL confirmed Patient 48, Patient 49, and Patient 50 had been included in the CL but were not on the eHRR. QCL stated only patients who received emergency care would be included on the eHRR. NM stated patients who had physician orders for outpatient services such as recurrent intravenous infusions, laboratory blood draws, or wound care entered the facility for the outpatient services through the ED entrance but were not seeking emergency care and should not have been included on the CL. NM confirmed Patient 48, Patient 49, and Patient 50 had physician orders for outpatient services.

In a review of a facility policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)", dated June 2023, the policy indicated, "Central log means a log maintained by the hospital recording the names who come...seeking emergency assistance and the disposition of each individual ... [and] does not apply to an outpatient."