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ASCENSION ST JOHN MEDICAL CENTER 1923 SOUTH UTICA AVENUE TULSA, OK 74104 Feb. 13, 2019
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on record review and interview, the hospital failed to enter into the Emergency Department (ED) log the disposition for 28 entries for the period from 01/01/19 through 02/11/19.

This failed practice resulted in the hospital's inability to track the disposition of all individuals presenting to the ED seeking emergency medical attention as defined by EMTALA regulations.

Findings:

Review of hospital policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA), revised 01/17" showed all patients who entered the ED "seeking treatment" would be entered into the log ...the log would contain whether the patient was transferred, admitted , transferred or discharged .

Review of the ED log from 01/01/19 through 02/11/19 showed 28 entries with no evidence of documentation of the patient's disposition.
On 01/02/19 one ED log entry had no disposition identified.
On 01/10/19 two ED log entries had no disposition identified.
On 01/15/19 one ED log entry had no disposition identified.
On 01/30/19 one ED log entry had no disposition identified.
On 01/31/19 two ED log entries had no disposition identified.
On 02/04/19 two ED log entries had no disposition identified.
On 02/05/19 two ED log entries had no disposition identified.
On 02/06/19 two ED log entries had no disposition identified.
On 02/07/19 12 ED log entries had no disposition identified.
On 02/08/19 one ED log entry had no disposition identified.
On 02/09/19 one ED log entry had no disposition identified.
On 02/10/19 one ED log entry had no disposition identified.

On 02/12/19 at 9:37 am, Staff A stated a rapid triage form was used to initially triage the patient at the time of registration and determine a triage level. Staff A stated the information obtained from the rapid triage form such as the patient's name, age, date, arrival time, and triage level was extracted to form the ED log. Staff A stated the patient's disposition would be obtained during the "check-out" process at the time the patient was discharged , transferred or admitted .