HospitalInspections.org

Based on interview, review of the Emergency Department log, medical records, and facility policy, the hospital failed to ensure the central log included the disposition of every individual seeking care for 12 of 20 sampled patients, (Patient Identifiers #7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18).

The findings include:

A review of facility policy concerning the Emergency Department (ED) log, titled "Compliance & Ethics Program Manual" revealed the following: "The log must document the patient's chief complaint, diagnosis, and disposition (e.g., discharge, admission, transfer, left without treatment (LWT), left against medical advice (AMA)."

Review of Patient Identifier (PI) #7's medical record revealed the patient was transferred to another facility. Review of the medical record for PI #10 revealed the patient was discharged from the ED. Reviews of medical records for PI #8, 9, 11, 12, 13, 14, 15, 16, 17 and 18, revealed the patients left without treatment.

A review of the the Emergency Department log for 7/01/20 did not include the final disposition for PI #7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 and 18.

During an interview with the Risk Manager on 7/8/20 at 3:43 PM, he confirmed the final disposition for all patients was not documented on the ED log.