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UPMC MEMORIAL 1701 INNOVATION DRIVE YORK, PA 17408 March 7, 2019
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of facility documents, video and staff interviews (EMP), it was determined that UPMC Pinnacle Memorial failed to ensure that an individual who came to their Emergency Department seeking assistance, was entered onto the Log, for one of one patients identified (OTH1).

Findings include:

A review of facility policy "Emergency Medical Treatment and Patient Transfer, revision Date: 3/19/2018" revealed "...Central Log means a log the Hospital maintains of all individuals who present to the Hospital seeking emergency medical assistance and the disposition of such individuals, whether the person refused treatment, was transferred, was admitted and treated,was stabilized and transferred, or discharged . The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an Emergency Medical Condition..."

An interview conducted on March 6, 2019, with EMP2 revealed that the registrar on duty on the Emergency Department was on administrative leave pending the investigation and would not be available for interview. The registrar was to register patients as they enter the Emergency Department and collect the patient's name, date of birth and chief complaint. After the information is collected, the information goes on the Emergency Department Log (computerized log) and on to the tracking board for the staff to triage and start the process in the Emergency Department. The facility does have two statements from the registrar about the events.
The two statements from the registrar were reviewed. The statements were conflicting. The review of the registrar's statement dated 3/5/19, revealed that the registrar was not sure how to handle patient and did not check with the triage nurse because " Yelled at her (Patient's parent) - felt pressured to give her the phone number (for True North).


A review of facility policy revealed " Emergency Department Check-in, last reviewed 07/20/18." Policy Statement: to document the procedure to perform an` Arrival and then complete the full Registration.
Procedure Guidelines:
Arrival
1. ED Registrar selects "Arrival" from the EPIC Homepage.
2. Enter the full name, DOB and gender and search for the patient.
3. If search returns you(sic) patient, choose the "select" button.
4. IF(sic) the search does not return your patient, click the "New" button.
5. Registrar then values or confirms required data, i.e.. means of arrival, escorted by and ED arrival date/time.
6. Click "close"
7. Patient will now appear on the ED Track Board...

Unidentified Patient ED Check In:
1. If patient identification is not available, ED registrar will complete an Arrival and will check "Anonymous" to autofill generic patient information for the unidentified patient.
2. Unidentified patient will appear on the EPIC Track Board with a generic patient and DOB.
3. The ED will make every attempt to obtain patient information. If the patient is checked in, the patient's generic information will remain on the Track Board until a legal name has been entered.
4. Patient Registration/Patient logistics will be notified if the patient's identity is discovered so patient data can be updated in EPIC..."

An interview conducted on March 6, 2019, with EMP5 revealed that EMP5 was the Charge Nurse on duty on February 25, 2019. EMP5 revealed that the nursing staff was not aware that the patient was in the hallway of Emergency Department. The patient and family were not in the waiting room and the Emergency Department staff became aware of the family. The Crisis Worker told the staff and talked with the patient and family. The family left before the staff could talk with the family. The patient was not seen by a provider and was not registered on the ED log. EMP5 stated when a patient is registered on the log that some of the patient information goes on the tracking board. We would not know about the patient if the patient is not registered. We do have a process for patients that will not or cannot give their name and date of birth. This is usually used for patient that are confused, or unconscious and do not have family with them.

An interview conducted on March 6, 2019, with EMP4, revealed that EMP4 was the Triage Nurse on duty on February 25, 2019. EMP4 stated that EMP4 was not aware of the patient and family in the hallway until a telephone call was received by the Crisis Worker. EMP4 stated that the Crisis Worker called while walking in the door of the ED, talked with the family who was angry with the one hour wait and left. The Crisis Worker then talked with the Triage Nurse and Charge Nurse who confirmed the patient was not on the log and was not seen by a provider.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on a review of facility policy and documents and staff interviews (EMP), it was determined that the facility failed to provide an appropriate medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed for one of one patient identified (OTH1).

Findings include:

A review of facility policy "Emergency Medical Treatment and Patient Transfer, revision Date: 3/19/2018" revealed "...I. Medical Screening Examination: A. Medical Screening. When an individual comes to the Emergency Department of the Hospital, or to any location on the Hospital's campus...and a request is made on the individual's behalf for a medical examination or treatment, an appropriate Medical Screening Examination,...shall be provided to determine whether an Emergency Medical Condition exists... It must be remembered that a Medical Screening Examination goes beyond initial Triage. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the order in which patients will be seen, not the presence or absence of an Emergency Medical Condition. Also, a Medical Screening Examination is not an isolated event, it is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until the patient is stabilized, discharged , admitted , or appropriately transferred.

Medical Screening Examinations shall be performed by an Emergency Department physician or another licensed practitioner as appointed and approved by the Hospital's Medical Staff and Board of Trustees..."

An interview conducted on March 6, 2019, with EMP1 and EMP2 revealed that the patient in question presented to the ED with a parent. The family left the ED and the patient was not registered, was not seen by a provider, and did not receive a medical screening examination.

An interview conducted on March 6, 2019, with EMP4, revealed that EMP4 was the Triage Nurse on duty on February 25, 2019. The patient was not added to the log and was not seen by a provider.