HospitalInspections.org

Based on document review & interview, the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 26 patients presenting to the facility. (Patient #26)

Findings include:

1. Review of policy/procedure Screening and Transfer of Emergency or Unstable Patients indicated the following on page 3;
D. Documentation
1. The emergency department will keep a log of each patient presenting for medical care. This log will include whether the patient refused treatment, left against medical advice, was transferred, admitted, or discharged.
This policy/procedure was last reviewed/revised on 09/11/2016.

2. On 05-03-17 at 1025 hours staff #42 confirmed that on 04-23-17 between 1015 - 1040 hours the Emergency Department (ED) was evacuated and patients were brought back into the ED at approximately 1045 hours. While the ED was evacuated staff #46 had a mother & son approach him/her and the mother asked should I go somewhere else. Staff #46 indicated could go elsewhere, but facility could provide care. There was no further conversation. The mother & son looked around & left.

3. Review of the ED Activity Log lacked documentation that patient #26 presented to the facility on 05-03-17.

4. On 05-03-17 at 1315 hours staff #44 confirmed that patient #26's visit to the facility on 04-23-17 was not recorded in the facility ED Activity Log.