The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Intakes: TN 297

Initial Comments:

An investigation of a possible EMTALA was initiated on 09/14/2015 and concluded on 09/16/2015. EMTALA investigative guidelines and procedures were followed. As a result of the investigation, deficient practice was identified at 42CFR 489.24 (A2405), "Maintain a Central Log " on patients who come to the Emergency Department.

A 90 day termination notice was sent by overnight mail to the hospital Administrator on October 21, 2015 with a termination date of January 19, 2016 for complaint numbered NC .

Based on review of the hospital's Emergency Department (ED) Central log, the Emergency Medical Services (EMS) ambulance report, the hospital's ED policy and interview, the hospital failed to ensure that each patient who presented to the hospital's ED was documented on the hospital's ED central log for 1 of 3 (Patient #1) sampled patients who had presented to the hospital's emergency department but left prior to the Medical Screening Examination (MSE).

The findings included:

1. Review of the hospital's, "EMTALA" policy revealed, "...Central Log...The Hospital should maintain a Central Log on each individual who 'comes to the emergency department, '...seeking assistance...'

2. Review of the Hospital #1's ED central log dated 8/29/15 revealed no documentation that Patient #1 had presented to the hospital's ED seeking care.

3. Review of Hospital #2 ED Triage Form revealed Patient #1 was triaged 8/29/15 at 5:56 AM with chief complaint of "... abdominal pain all night. was at [Hospital #1] and left. Has had bowel obstruction in the past and thinks he does again..." Patient #1 was admitted to Hospital #2's Inpatient Telemetry Unit at 8/29/15 at 8:40 AM.

4. Review of the EMS ambulance Report dated 8/29/15 revealed Patient #1 was transported to and arrived at the Hospital #1's ED at approximately 1:47 AM.

5. Review of the hospital's security video of 8/29/15 at 1:48 AM revealed EMS unit arrived on the hospital's property and later left the hospital's property.

6. During an interview in the conference room on 9/14/15 at 2:10 PM the Director of Quality/Performance Improvement & System Regulatory verified Patient #1 was not on Hospital #1's ED central log. The Director stated when a patient leaves the ED, a depart form is completed. When the depart form is completed, it causes the patient information to print on the central log. He further stated, "... I know we have to have a log but I don't think there is a regulation that says it has to be 100% accurate..."