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Based on review of video recordings, facility policies and procedures, Medical Record (MR) reviews, Patient Sign In sheets, Emergency Medical Services (EMS) run report, and interviews it was determined the facility failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 (PI # 1) of 21 sampled patients ED medical records.

This deficient practice had the potential to affect all patients presenting to the hospital ED for treatment.

Refer to tag A 2406 for findings.

PI # 1, a minor child, suffered a dog bite to the thigh on 3/17/22 and was brought to Dale Medical Center ED (Hospital A) seeking care. The registration clerk informed the ED physician of the child's presence. The ED physician instructed the registration clerk to have the father hold pressure on the site until they could be seen. The registration clerk stated to the family member the ED was understaffed and they could take the child if they knew of anybody that could treat them sooner. The family left Dale Medical Center to seek treatment at Hospital B. PI # 1 was treated and stabilized at Hospital B and transferred to Hospital C.

Based on observational tours, and interview, it was determined the hospital failed to ensure signs specifying the rights of individuals with emergency medical conditions and women in labor were posted.

This deficient practice had the potential to affect all patients arriving at the Emergency Department (ED).

Findings include:

An observational tour of the ED was conducted on 3/28/22 at 11:50 AM with Employee Identifier (EI) # 5, Chief Executive Officer. During the tour of the ED revealed, there were no signs posted at the ED entrance, ED lobby, or registration area specifying the rights of patients with emergency medical conditions and women in labor.

In an interview conducted on 3/28/22 at approximately 1:00 PM, EI # 5 confirmed the signs were not posted.

Based on review of the Emergency Department (ED) log, video recordings, facility policy, observational tour, and interviews, it was determined the facility failed to ensure each patient arriving at the hospital seeking emergency treatment was entered in the ED log accurately.

This deficient practice had the potential to affect all patients arriving at the hospital ED seeking treatment.

Findings include:

Facility Policy: EMTALA/COBRA - Medical Records and Central Logs - Policy Number: 8969341, Last Revised: 03/2021, was reviewed. The policy revealed in part, "Central Logs - A presentation log will be maintained for all persons presenting in the emergency care areas of the facility..."


1. On 3/28/22 at 4:00 PM a review of the video recordings from 3/17/22 of the ED entrance was conducted with EI # 6, Plant Manager. Review of the video recording verified that Patient Identifier (PI) # 1 presented to the ED on 3/17/22 at 5:21 PM. Continued review of the video recording revealed on 3/17/22 at 5:21 PM a man carrying PI # 1 (identified by EI # 6 as PI # 1) into the ED entrance. Further review of the video revealed on 3/17/22 at 5:23 PM the man carrying PI # 1 leaving the ED at 5:24 PM.

A review of the ED log provided to the surveyors on 3/28/22 revealed no documentation of PI # 1 arriving at the ED for emergency treatment on 3/17/22. The facility failed to ensure their policy and procedure was followed as evidenced by failing to maintain an ED log for PI # 1 who presented to the hospital's ED on 3/17/22 seeking treatment.

In an interview conducted on 3/29/22 at 10:20 AM EI # 7, Registration Clerk, stated on 3/17/22 a man came in carrying a child who had been bitten by a dog and was bleeding. "I told them we were understaffed and went and talked to the doctor and told (the doctor) what was out there... (The doctor) said to tell them to put pressure on it and it would be a minute. I went out and told them and said they could take her somewhere else if they knew of anybody who could treat them quicker."

In an interview conducted on 3/29/22 at 2:47 PM, EI # 12, Nursing Supervisor, was asked about the process when a patient comes to the ED. EI # 12 stated "when a patient comes in they sign in with name, date, and time. The clerk turns on the little light to let the nurse know. If not urgent after triage they are sent back out to the lobby."

An observational tour of the ED registration area was conducted on 3/30/22 at 10:00 AM. EI # 9, Registration Clerk, was asked how the patients are signed in. EI # 9 showed the surveyor a sign in sheet for the day which included the name of the patient, date of birth, and time of arrival. EI # 9 was asked if the sign in sheets were kept as part of the record. EI # 9 responded, "no, when the sheet is full we put it in the shred box".

In an interview conducted on 3/30/22 at 1:35 PM, EI # 4, Medical Records, Business Office Supervisor, and ED Clerk Supervisor, was asked if the sign in sheets were kept. EI # 4 responded "no".

EI # 4 was asked who completes the ED log. EI # 4 stated, "The clerk fills it out once the patient is registered, which is after triage. The time in the log is the time the patient was registered."

EI # 4 was then asked about the process when a patient arrives at the ED. EI # 4 responded "when a patient comes to the Emergency Room they come straight to the (ED clerk's) window. They sign in with name, date of birth, and time. The clerk flips the light switch to let the nurse know they have a patient for triage then asks the patient to have a seat. They are then called back by the triage nurse, if there is no room they (the patient) comes back to the lobby until a room is available. The clerk registers the patient after triage and then takes the papers to the back to enter into the ED log."

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to maintain an ED log for 1 (patient #1) of 21 patients who presented to the emergency care area seeking medical care.

Based on review of video recordings, facility policies and procedures, Medical Record (MR) reviews, Patient Sign In sheets, Emergency Medical Services (EMS) run report, and staff interviews it was determined the facility failed to ensure an appropriate medical screening examination was provided within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists for 1 (PI # 1) of 21 sampled patients ED medical records.

This deficient practice had the potential to affect all patients presenting to the hospital ED for treatment.

Findings include:

Review of the facility's Policy entitled "Medical Screening Examination" Policy # 8969041, Last Revised: 03/2021, revealed in part, "The initial, and on-going, evaluation of the presenting patient conducting by a physician, including history, physical examination, appropriate testing, completion of appropriate documentation , and evaluation of the patient, within the capabilities of this hospital utilizing those facilities routinely available to the emergency department including the use of indicated on-call physicians as appropriate, to determine whether a patient has an emergency medical condition as defined by law and/or to ensure that the patient does not have an emergency medical condition condition as defined by law."

Facility Policy: EMTALA/COBRA - General Policy Statement, Policy # 8975628, Last Reviewed: 04/2021 was reviewed. The Policy and Procedure revealed in part, "Procedure:...No patient presenting shall be denied triage or medical screening examination by any employee or medical staff member of this hospital. The patient shall not be discouraged from utilization of these services..."

In an interview conducted on 3/28/22 at 4:00 PM Employee Identifier (EI) # 6, Plant Manager, was asked if the hospital has videos of the ED. When EI # 6 was asked for video recordings, EI # 6 stated, "I think I know which day you want to look at. On 3/17/22 a little girl (PI # 1) with a dog bite was brought to the emergency room."

Review of the video revealed on 3/17/22 at 5:21 PM a man carrying PI # 1 (identified by EI # 6 as the child with the dog bite) into the ED entrance. Further review of the video revealed on 3/17/22 at 5:23 PM the man was seen carrying PI # 1 from the ED at 5:24 PM.

In an interview conducted on 3/29/22 at 10:20 AM EI # 7, Registration Clerk, stated on 3/17/22 a man came in carrying a child who had been bitten by a dog and was bleeding. EI # 7 stated " I told them we were understaffed and went and talked to the doctor and told (him/her) what was out there. Told (him/her) we had a patient who had been bitten by a dog and was bleeding. (He/She) said to tell them to put pressure on it and it would be a minute. I went out and told them and said they could take (him/her) somewhere else if they knew of anybody who could treat them quicker. The father said "F" this and walked out."

In an interview conducted on 3/29/22 at 2:32 PM, EI # 11, ED Physician, stated, "...I did not see (him/her PI # 1) but I remember the receptionist came back to let me know. (He/She) told me there was a kid with a dog bite who was bleeding. I told (receptionist) to tell the dad to put pressure on it and we were coming."

According to review of the video surveillance PI # 1 left prior to the ED physician seeing the patient. There was no documentation of the patient in the ED log and no documentation of a MSE.

According to the medical record from Hospital B, PI # 1 arrived at Hospital B's ED on 3/17/22 at 5:50 PM with complaint of a dog bite to the left thigh area with deep soft tissue damage. The Vital Signs were Blood Pressure (BP) 104/53, Pulse 66, Respirations 24, Pulse ox (oximetry) 98 %, and Temperature 97.8. Review of the x-ray of the left femur report revealed no acute bony abnormality but significant soft tissue injury is suggested.

Review of the ED physician documentation revealed that PI # 1 was initially seen by the ED physician on 3/17/22 at 6:08 PM. Further review of the section of the note titled "Physical examination" revealed in part, "Skin: gaping wound to medial (L) thigh with hanging skin edges and tissue loss...two smaller lacerations noted on (L) lateral thigh." Continued documentation revealed a diagnosis of Closed animal bite and tendon laceration. It was determined that PI # 1 was certified as a Medical Emergency. The Plan was to transfer PI # 1 for plastic surgeon evaluation. Further review of the ED physician documentation revealed the patient was accepted for transfer by Hospital C on 3/17/22 at 7:20 PM. Arrangements were made for ground transport.

Review of the Emergency Medical System (EMS) Run report completed on 3/18/22 at 5:54 AM for the run completed on 3/17/22 revealed EMS was enroute with (PI # 1) from Hospital B from 8:37 PM and arrived at Hospital C at 11:05 PM on 3/17/22. Enroute Vital Signs were: BP 109/66, pulse 100, respirations 22.

Review of Hospital C's medical records revealed PI # 1 arrived on 3/17/22 at 11:09 PM. Surgery was consulted for complexity of repair of left thigh wound. PI # 1 was taken to surgery on 3/18/22 at 3:27 AM., for debridement of (L) thigh wound, The patient was admitted to Pediatric General surgery.

Hospital A failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate MSE was performed for PI # 1 within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for PI # 1 on 3/17/22.