HospitalInspections.org

Based on record review and interview, it was determined that the Emergency Department (ED) did not ensure that the log of patient encounters was accurately maintained.

Findings include:

Review of ED logs on 7/29/14 of emergency room patient encounters for a four month period (from April through July 2014) found references to patients who left without triage. It was noted that no entries were found in the log for patients who left before triage whose mode of arrival was by Emergency Medical Services (EMS).

At interview with the Risk Manager on 7/29/14, it was stated that the ambulance call reports (ACR's) have been electronic and without an internet connection to the Fire Department of New York wireless system, there would be no electronic record received of the ambulance call report maintained. There were no copies of ACR's maintained in the ED that would generate an electronic medical record and therefore an entry into the ED log. As a result, for at least four months, there was no record of EMS encounters in the ED log for patients who were transported to the ED by EMS but who walked out and left prior to triage.

Once the Risk Manager was notified of this finding on 7/29/14, the facility staff took immediate corrective action. Coordination between the New York City Fire Department Technology unit and the hospital's Information Technology unit, along with the hospital's Engineering Department, resulted in the ability to create an internet connection to obtain the required electronic ambulance call report ACR documents.