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Based on record review and interview, the hospital failed to ensure central log documentation for one (Pt #21) of 21 ED patients reviewed. This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum. (see 2405)

Based on record review and interview, the hospital failed to ensure provision of an appropriate MSE for one (Patient #21) of 21 ED patients reviewed. This failed practice had the likelihood to result in unrecognized emergency medical condition, delay in treatment and adverse patient outcomes. (see 2406)

Based on record review and interview, the hospital failed to ensure central log documentation for one (Pt #21) of 21 ED patients reviewed.

This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum.

Findings:

Pt #21
Review of the ED central log showed no documentation of an ED visit on 07/15/25 by Pt #21.

On 07/15/25 at 2:52 pm Staff D stated, "A gentleman came to the window and said she is pregnant, and she is having contractions about one minute apart. I said we don't have an OB department more than likely we would have to send you out. They asked where? I said probably Shawnee they can accommodate a delivery. The man said Oklahoma City that was where her doctor was, and it was 45 minutes away as well. The woman shook her head yes and they turned and left. I was confused because we don't have an OB department and was unsure of what treatment."

Staff D then stated basically anyone who comes to the ER should be registered.

Based on record review and interview, the hospital failed to ensure provision of an appropriate MSE for one (Patient #21) of 21 ED patients reviewed.

This failed practice had the likelihood to result in unrecognized emergency medical condition, delay in treatment and adverse patient outcomes.

Findings:

Review of hospital records showed no documentation Pt #21 received an MSE.

A review of a policy titled "5007 - EMTALA Guidelines" read in part, "All patients should receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis."

Review of an internal hospital document dated 07/10/25 and signed by Staff D read in part:
"On July 7th 2025 a young man and young lady came into the ER. The young man approached the window and started saying she's pregnant, pointing to the young lady coming in behind him... continued saying they were headed to Oklahoma City because that's where their doctor is and that her contractions are about a minute apart. I said we do not have an OB department and that she would probably have to be sent out to another hospital. I do not recall this type of scenario being covered in training. I said that Shawnee has an OB department and they are about 45 minutes away...."

A review of a security video at the ED entrance dated 07/07/25 showed:
1) 11:43 am a man and a woman wearing a long blue t-shirt and shorts who had a rounded abdomen entered the ED;
2) 11:44 am they were at the ED registration desk; they appeared to speak with someone then turned and exited the ED walking outside.

On 07/15/25 at 2:38 pm Staff B stated, Pt #21 did not receive an MSE.