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Tag No.: A2402
Based on observation and interview, the facility failed to display conspicuously in the Emergency Department the Emergency Medical and Treatment Act (EMTALA) signage that specified the rights of patients to examination and treatment of emergency medical condition, and for women in labor
Findings include:
During tour of the Emergency Department on 01/18/18 at approximately 2:00 PM, there was no EMTALA signage posted at the Emergency Room walk in entrance, Ambulance entrance, the waiting and treatment areas.
The EMTALA signage posted behind the information desk in the Adult Mini-Registration/Pre-triage area was not easily visible to patients. Another sign posted by the Registration Desk in English and Spanish was in small print and above eye level, which made it difficult to read.
During interview with Staff U, Coporate Director, on 1/8/18 at approximately 2:00 PM, she acknowledged findings.
Tag No.: A2405
Based on medical record review, document review and interview, the facility failed to maintain an accurate Emergency Department (ED) log. Specifically, the disposition of each patient was not accurately documented in the log.
Findings include:
Review of the ED log for 10/1/2017 revealed the disposition of Patient #2 was noted as "01- quick reg". However, the review of the patient's medical record revealed the patient was treated and discharged home.
The log for 1/11/2018 revealed that Patient #14 walked out of the ED. Review of the patient's medical record showed that the patient was evaluated and treated, but was discharged against medical advice.
Similar findings were noted in Patient #s 15 and 18 whose disposition in the medical record does not match the disposition recorded in the ED log.
During interview with Staff U, Corporate Patient Service Director on 1/19/18 at approximately 10:00 AM, she acknowledged findings.
Tag No.: A2406
Based on document review and interview, in one (1) of 12 Emergency Department (ED) records reviewed, the facility failed to provide a medical screening examination to a patient who presented to the ED with suicidal ideation (Patient #2).
This failure may result in an emergency medical condition not being identified and treated.
Findings include:
Review of document titled "Register Emergency Room Patient" noted: Patient #2, a 39-year-old, presented to the facility's ED 10/01/17 04:06 PM with a complaint of suicidal ideation. Patient stated she has a plan to cut herself, but came to ED instead. The patient was assigned a Triage Category: Level 2 (High risk/needs rapid intervention or sight is threatened) and was taken to the ED Treatment Area.
There was no evidence that Patient #2 was subsequently triaged and received a medical screening examination after patient was brought to the treatment area on 10/1/2017 at 4:06 PM.
During interview with Staff V, Triage Nurse on 1/23/2018 at approximately 2:00 PM, Staff stated the information listed on the "Register Emergency Room Patient" document, is from the Quick Registration (QER). She stated Intake nurse (Registered Nurse) as the first point of contact for all patients entering the Emergency Department. The Intake nurse gathers the name, chief complaint, travel history, selects disposition (wait in room or treatment area) and designates a triage classification based on the presenting complaint of the patient. The patient later undergoes a comprehensive triage in order of priority.
During interview with Staff U, Corporate Patient Service Director on 1/23/2018 at approximately 2:45 PM, she reported that the facility was not able to locate the electronic record for the patient's encounter on 10/1/2017. She explained that a medical record is created after a comprehensive triage assessment is completed and that Patient #2 was not further assessed. Staff U acknowledged there was no documentation of a comprehensive triage assessment or medical screening evaluation after the patient was seen by the Intake nurse on 10/01/17 at 04:06 PM.