HospitalInspections.org

Based on document review and interview, it was determined that for 54 patients that presented to Emergency Department (ED) between 3/27/2023 and 9/5/2023, the Hospital failed to ensure that the ED's central log was complete and included the patient's discharge disposition.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA), dated 11/2022, was reviewed on 9/6/2023, and required, "The purpose of this policy is to set forth policies and procedures for [Hospital]'s use in complying with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA)...C. Central log. The Hospital must maintain a central log of individuals who come to the emergency department and include in such central log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged..."

2. The Hospital's ED Central logs from 3/27, 4/27, 5/27, 6/27, 7/27, and 9/5/2023, were reviewed on 9/6/2023. The logs from these dates lacked the patient's dispositions as follows:

- 3/27/2023: 6 of 106 patients lacked dispositions.
- 4/27/2023: 9 of 108 patients lacked dispositions.
- 5/27/2023: 8 of 102 patients lacked dispositions.
- 6/27/2023: 16 of 111 patients lacked dispositions.
- 7/27/2023: 15 of 101 patients lacked dispositions.

3. On 9/6/2023 at 11:45 AM, an interview was conducted with the ED Director (E #1). E #1 stated that although there is a separate report ran that includes all the patient's information, E #1 acknowledged that the ED central logs lacked complete information including some missing dispositions.