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Based on interview and record review, the hospital failed to ensure the ED Central and L&D Department Logs were accurately maintained for four of 20 sampled patients (Patients 4, 14, 16, and 18) and for three nonsampled patients (Patients 21, 22, and 23). This failure had the potential to result in the hospital not being able to accurately track the care provided to the individuals who presented to the ED and L&D department for the treatments of their emergency medical conditions.

Findings:

Review of the hospital's P&P titled EMTALA - Central Log Policy dated March 2023 showed in part:

* The hospital must maintain the Central Log in an electronic or paper format.

* The logs must contain at a minimum, the name of the individual; the date, time and means of the individual's arrival; the individual's age; the individual's sex; the individual's record number; the nature of the individual's complaint; the individual's disposition; the individual's time of departure; and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged or expired.

a. On 7/16/24, a random review of the L&D Department Logs for May, June, and July 2024 showed the L&D Department Logs were not completed in its entirety as evidenced by:

* On 5/20/24, the mode of arrival was not completed for Patient 21.

* On 6/20/24, the disposition time was not completed for Patient 22.

* On 7/2/24, the disposition time was not completed for Patient 23.

On 7/16/24 at 1445 hours, the Director Perinatal Services acknowledged the findings and confirmed the L&D Department Log had not been maintained.


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b. On 7/17/24 at 1400 hours, an interview and concurrent record review was conducted with the Quality Manager.

Review of Patient 14's ED Triage Aware Note dated 6/9/24, showed Patient 14 arrived to the ED at 2136 hours with a chief complaint of "wound check".

However, review of the ED Central Log dated June 2024 showed Patient 14's chief complaint was "5150 Hold".

On 7/18/24 at 1045 hours, an interview was conducted with the Interim Director of ED Services, the Interim Director of ED Services acknowledged the above findings and confirmed the chief complaint listed on the ED Central Log for Patient 14 was incorrect.

c. On 7/17/24 at 1400 hours, an interview and concurrent record review was conducted with the Quality Manager.

Review of the ED Central Log dated June 2024 showed Patient 16's Disposition was "Hold."

Review of Patient 16's Patient Information sheet dated 7/16/24, showed under encounter information, Patient 16 was admitted on 6/9/24 at 1237 hours under the service of telemetry.

On 7/18/24 at 1045 hours an interview was conducted with the Interim Director of ED Services, the Interim Director of ED Services acknowledged the above findings and stated the ED Central Log for Patient 16 should have shown the disposition of "admitted".


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d. On 7/16/24 at 1400 hours, an interview and concurrent record review was conducted with the Interim Director of ED Services.

Review of Patient 18's Progress Notes dated 7/2/24, showed Patient 18 arrived to the ED at 1259 hours but had left prior to being triaged. The Progress Notes showed Patient 18 was called for triage multiple times at 1307, 1316, and 1352 hours but was not found.

However, review of the ED Central Log dated July 2024 showed Patient 18's Disposition was "Treatment in."

The above findings were verified by the Interim Director of ED Services who stated the ED Central Log should have shown Patient 18 had left before being triaged.

e. On 7/16/24 at 1400 hours, an interview and concurrent record review was conducted with the Interim Director of ED Services.

Review of Patient 4's ED Trauma Team Assessment dated 7/4/24, showed Patient 4 arrived to the ED at 2138 hours and was admitted to inpatient on 7/5/24 at 0405 hours.

However, review of the ED Central Log dated July 2024 showed Patient 4's Disposition was "433."

The above findings were verified by the Interim Director of ED Services who stated the ED Central Log should have shown Patient 4 was admitted.