HospitalInspections.org

Based on a review of facility documents and staff interviews (EMP), it was determined that Tyrone Hospital failed to maintain a Central Log for one of one patients presenting to the Emergency Department. (OTH1)

Findings include:

Review of "... EMTALA - Central Log" effective date May, 2009, revealed, "...1. The Central Log will include an entry for EVERY patient that comes to the ED seeking treatment. ... 3. The Log must contain: ... d. whether the individual: i. refused treatment; ii. was refused treatment iii. left without being seen (LWBS); ... ."

1) Review of Emergency Department Log dated January 1, 2012, to July 31, 2012, revealed no documented evidence that OTH1 had presented to the Emergency Department of Tyrone Hospital.

2) An interview was conducted with EMP2 on August 6, 2012, at approximately 9:45 AM. EMP2 confirmed the above findings and revealed, "I received a complaint letter on July 25, 2012. The complainant revealed that they had presented to our ED. Upon review the complainant was not in our Log and we do not have any documentation of a medical record."

Based on review of facility documents, and staff interviews (EMP), it was determined that Tyrone Hospital failed to provide a medical screening examination for one of one patients presenting to the Emergency Department.

Findings include:

Review of policy, "EMTALA-Medical Screening Examination and Stabilization Policy" dated 2011/2012, revealed, " ... III. Purpose: To establish guidelines for providing appropriate medical screening evaluations and, if the individual is determined to have an emergency medical condition, any necessary stabilizing treatment as required by the Emergency Medical Treatment and Labor Act (EMTALA), 42 U.S.C., Section 139dd and all Federal regulations and interpretive guidelines promulgated thereunder. IV. Text: When an individual comes to the Emergency Department (ED) and a request is made on his or her behalf for an examination or treatment for a medical condition, ... an appropriate medical screening examination (MSE), within the capabilities of the hospital's ED ... shall be performed by an individual qualified to perform such an examination to determine where an EMC exists ... ."

Review of facility documentation revealed no documented evidence of a medical screening completed for OTH1 who had presented to the Emergency Department on July 10, 2012.

1) Interview with EMP2 on August 6, 2012 at approximately 3:00 PM confirmed the above findings and revealed, "The triage paper was shredded since the patient did not stay."