HospitalInspections.org

Based on review of hospital documents and the emergency department/room (ER) log and interviews with hospital staff, the hospital failed to maintain a complete ER log with the required information.

Findings:

1. Policy review:
a. Upon arrival on the afternoon of 11/09/2010, the surveyors requested the hospital's policies and procedures concerning EMTALA (Emergency Medical Treatment and Labor Act). The policy and procedure manual for the ER brought by the Nurse Manager did not contain a policy concerning the ER log with information as to the required contents for the ER log and designation of the staff responsible for completion of the log.
b. On the afternoon of 11/09/2010, Staff C confirmed the hospital did not have a policy concerning the ER log. She told the surveyors that the unit clerks usually filled out the ER log.
c. Staff D stated at 0850 on 11/10/2010 that unit clerks filled out the log and drew lines through entries when the patient did not "go back" to the examination area and would write void and/or LWOBS (left without being seen). On 11/10/2010 at 0945 Staff E confirmed this as the practice followed.

2. The ER log did not contain an entry for Patient #1's visit on the evening of 10/29/2010. The log did contain a blank space between patients presenting at 1902 and 2021, with a visit record number, date of 10/29/2010 and then a line through the rest of the line with "void" written in. The surveyors requested the visit record number. The record retrieved was for the patient mention in the complaint.

3. The surveyors reviewed the ER log for completeness for the time period of May 1, 2010 through November 6, 2010. Besides the entry mention in Finding #2, the ER log did not contain the dispositions for:
a. One entry for November 2010,
b. Four entries for October 2010,
c. Eight entries for September 2010,
d. Two entries for August 2010,
e. Five entries for July 2010,
f. Ten entries for June 2010.

4. The surveyors reviewed and verified the findings with the Chief Nursing officer and Staff C on the afternoon of 11/10/2010.