HospitalInspections.org

Based on interview and document review the facility failed to log 1 patient (P-1) of 20 patients, who presented to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients who left the facility without being seen and the potential for less than optimal outcomes. Findings include:

On 10/02/23 at 0910, during the tour Staff I was interviewed and stated she has worked at the facility for" just about a year" and has received EMTALA training upon her "hiring and then on a yearly basis." Staff I stated she knows that "EMTALA" means the ED "cannot refuse treatment for any reason". Staff I was queried in regard to "some equipment being down" and if she ever told the patient that they "would need to go to another facility for treatment", Staff I denied ever sending anyone away. Staff I said, "I would never do that." When queried about adding patient to the "Emergency Department Log" Staff I stated "if the patient doesn't want to stay (for whatever reason), and we didn't get their full name, they don't get added to the log. Staff I stated that it takes both the first and last name to generate a chart and an ED visit to generate into the "Emergency Department Log".

On 10/02/23 at 1000 during document review it was determined that Patient (P-1), could not be identified according to the facility's ED Log from the last name that was provided by the complainant.

On 10/02/23 at 1130 review of hospital policy MHC_CC0125, EMTALA: Treatment of Emergency Medical Conditions and Patient Transfers Policy 3.6 Emergency Medical Care/EMTALA Log is defined as a record of patients seeking emergency medical services at Hospital...4.2 Emergency Medical Care Log stated, "Any patient seeking emergency medical services will be documented in the Log in the Department that provided the MSE (Medical Screening Exam) and treatment".
5.3 Emergency Medical Care Log. The hospital will document information of the patients seeking emergency medical services in the Log. The Log will include:
5.3.1. Patient Identifier
5.3.2. Medical Record / Encounter Number
5.3.3. Patient Type (emergency/Fast Track)
5.3.4. Presentation time
5.3.5. Triage time
5.3.6. MSE time
5.3.7. Discharge time
5.3.8. Disposition categorized as: ...5.3.8.5. Refusal of treatment.