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1401 E TRINITY MILLS ROAD

CARROLLTON, TX null

COMPLIANCE WITH 489.24

Tag No.: A2400

Based on record review and interview, the facility failed to ensure compliance with §489.24. EMTALA, in that, the central log did not include required data points:

14 of 27 patients (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) did not have a chief complaint listed, AND

1 of 27 patients (Patient # 1) did not have a discharge disposition listed.

Cross Reference A - 2405 42 CFR 489.20(r)(3)

EMERGENCY ROOM LOG

Tag No.: A2405

Based on record review and interview, the facility failed to ensure a central log on each individual who comes to the emergency department to include (chief) complaint and discharge disposition (Discharge Code) for all emergency patients, in that,

14 of 27 patients (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) did not have a chief complaint listed, AND

1 of 27 patients (Patient # 1) did not have a discharge disposition listed.

Findings

Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 did not have a chief complaint listed on the ER Log.

Patient # 1 did not have a discharge disposition (Discharge Code) listed on the ER Log.

During record review and interview on 7/17/2023 ending at 4:50 PM, Personnel #1 was asked to confirm chief complaint and discharge disposition was missing from patients on the ED Log. Personnel #1 reviewed the records and confirmed.

There was no policy provided to require all patients' information listed on an ER Log.