HospitalInspections.org

Based on review of the hospital's dedicated emergency department (DED) central log, medical record review and staff interviews, the hospital failed to ensure that each individual presenting to the DED seeking care for an emergency medical condition was included on the central DED log for 1 of 20 DED patients reviewed (Patient #14).

The findings include:

Closed medical record review of Patient #14 revealed a 2 year-old who presented to the hospital's DED on 03/06/2013 at 1102 with chief complaint of fever. Further record review revealed Patient #14 was triaged at 1143 and subsequently left without treatment (time unknown).

Review on 04/16/2013 of the hospital's central DED log revealed Patient #14 was not listed on the central log.

Interview on 04/16/2013 at 1440 with administrative staff confirmed Patient #14 was not listed on the central DED log. Interview further revealed, "Greenville (tertiary care hospital) may have done something to get him off the log so they could see the chart when he presented to their hospital". Interview revealed Patient #14 was coded in the system as "dismissed" and should have been coded as "LWOT (left without treatment)".

Interview on 04/16/2013 at 1445 with corporate administrative staff revealed the hospital had converted to a new computer system and they were having issues with the log. Interview revealed, "we will get this fixed".

NC00087605