HospitalInspections.org

Based on document review and interview, it was determined that for 20 individuals who presented to the ED from 4/25/2020-9/25/2020, the Hospital failed to ensure that the Emergency Department (ED) centralized log was maintained to include the disposition of each individual who presented to the ED.

Findings include:

1. The Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" (revised 2/11/2019), was reviewed on 10/06/2020 and required, "...Records and Retention: A centralized log of all patients presenting with a request for emergency care to the Dedicated Emergency Departments and Hospital Property shall be maintained and shall include the name of the patient, outcome, any refusal of care and whether the patient was admitted, stabilized and transferred, or discharged..."

2. The Hospital's ED centralized logs from 4/25/2020, 5/25/2020, 6/25/2020, 7/25/2020, 8/23/2020-8/29/2020, and 9/25/2020 were reviewed on 10/5/2020 and lacked documentation of the patients' disposition as follows:
- 4/25/2020: 1 of 29 patients
- 6/25/2020: 1 of 46 patients
- 7/25/2020: 2 of 50 patients
- 8/24/2020: 4 of 60 patients
- 8/25/2020: 4 of 42 patients
- 8/27/2020: 1 of 47 patients
- 8/28/2020: 6 of 46 patients
- 8/29/2020: 1 of 39 patients

3. An interview was conducted with Regional Director of Accreditation (E#1) on 10/6/2020, at approximately 3:15 PM. When asked about the missing disposition from the ED logs, E#1 stated, "I confirmed with the ED Manager, and it's inconsistent documentation. The staff did not go back in to the system [centralized log] to document the patients' dispostion [after the patients left the ED.] There were 16 [dispositions] missing just from the 8/23/2020 to 8/29/2020 log. That's a significant amount."