HospitalInspections.org

Based on document review and staff interview, the facility failed to maintain medical records for one (Patient #1) out of 20 patients who presented to the hospital emergency department from August 25 1, through October 10, 2023.
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The findings were as follows:
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Document Reviews:
1. A review of the central log for August 28 - 30, 2023, revealed that Patient #1 presented to the Emergency Department on August 30, 2023, requesting medical care or treatment.
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2. A request for one of the medical records, the record for Patient #1, was made on October 11, 2023, at approximately 1200 PM. The facility was unable to produce the medical record.
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3. The Facility's policy titled, 'EMTALA - Patient Registration' (originating and last revised on 04/2016, last reviewed and effective on 12/2022), stated on page 1 of 2:
" ...Rapid Registration information and a patient record shall be initiated for all patients who present to the ED, even if they choose to leave without being seen (LPMSE); leave prior to medical screening exam or before treatment is completed (LPT); or leave "against medical advice" (AMA). Partial records may be generated in these situations with as much information as available. Appropriate forms should be initiated with the patient by medical/nursing staff in these situations if possible.
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"Reasonable" registration information may be obtained per EMTALA guidelines as long as there is no delay in care. That may include demographics such as name, address, phone number, birth date/age, and presenting medical problem(s). The Hospital will use a "Rapid registration' that may use some or all of what is considered "reasonable." Failure to provide registration information may not, at any time, delay the medical screening examination (MSE) or stabilizing treatment ..."
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Emergency Room (ER) lobby and entrance security footage was reviewed:
4. A review of the facility's ER security camera footage on the afternoon of August 30, 2023, between 4:20 PM and 5:35 PM showed Patient #1, was at the Facility's ER for 62 minutes.
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Interviews:
5. On October 11, 2023, at approximately 1200 PM, Staff #3 indicated there were no medical records for Patient #1.
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Staff #3 stated that she did not know what happened to the handwritten paperwork that was seen on the facility's security footage given to Patient #1 or collected by a staff member.
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Based on medical record reviews, facility documentation reviews, and interviews, the facility failed to provide an appropriate medical screening examination (MSE) for one (Patient #1) of 20 patients whose records were reviewed. This resulted in Patient #1 leaving to seek medical treatment at a different facility.
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The findings were as follows:
Medical Record Reviews:
1. There was no patient record located for Patient #1 at the facility. The facility's Emergency Room (ER) register/log shows that Patient #1 signed in on August 28 - 30, 2023.
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Emergency Room (ER) lobby and ambulance bay security footage was reviewed:
2. A review of the facility's ER security camera footage on the afternoon of August 30, 2023, between 4:20 PM and 5:35 PM showed Patient #1, was at the Facility's ER for 62 minutes without receiving a medical screening exam.
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Observation of the facility's ambulance bay video footage revealed that Patient #1 was on her phone at 4:54 PM. EMS arrived at 5:05 PM, placed Patient #1 on a stretcher at 5:07 PM, and transported Patient #1 to another facility to obtain treatment.
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Policy Reviews:
3. The Facility's policy titled, 'EMTALA - Medical Screening Examination (MSE)' (originating and last revised on 04/2016, last reviewed and effective on 12/2022), stated on page one of three:
" ...The Hospital shall provide each individual who comes to the dedicated ED with an appropriate medical screening examination (MSE), within its capabilities to determine whether the individual has an emergency medical condition, regardless of the individual's ability to pay, race, color, national origin, age, sex, religion, or disability ..."
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And on page two of three:
" ...The ED shall generate a medical record for each individual who presents to the department, documenting the MSE provided. Such records shall be maintained in compliance with the Hospital's record retention policy and procedure ..."
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4. The Facility's policy titled, 'Patient Assessment and Triage Policy' (originating on 07/2016, last revised on 01/2022, last reviewed and effective on 12/2022), stated on page one of three:
" ...B. All patients presenting to the Emergency Department will be screened by priority placement (see Priority Patient Placement policy to define elements of triage) of sick, not sick while beds are open, when no beds open traditional triage will ensue as: triaged and categorized using the Emergency Injury Severity Index Scale known as ESI -5 level system ..."
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Interviews:
5. On October 11, 2023, at approximately 1200 PM, Staff #3 indicated there were no medical records for Patient #1.
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Staff #3 stated that she did not know what happened to the handwritten paperwork that was seen on the facility's security footage given to Patient #1 or collected by a staff member.
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