HospitalInspections.org

Based on review of the Emergency Room (ER) log, review of policies and interview with facility staff, it was determined the facility failed to track the care provided to each individual who presented to the ER for an emergency medical condition.
This deficient practice effected 34 emergency department patient entries but has the potential to affect all patients receiving ER services.

Findings Include:

1. Policy: Number: 03-26-47
Title: EMTALA: Central Log Effective Date: January, 1996

Purpose:
To track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.

Policy:
Each facility that provides emergency services will maintain a central log to include information on each individual who comes to the hospital requesting treatment,...

Procedure:
... 4. The log must contain: the name of the individual seeking assistance and the disposition (permitted dispositions include: 1) patient refused treatment, 2) was refused treatment by facility, 3) transferred, 4) admitted and treatment, 5) stabilized and transferred, or 6) discharged).

2. ED Log Entries
A review of the ER Central Log book from 12/12/10 to 1/17/11 conducted by the surveyor on 1/18/11 at 12:10 PM revealed 10 of 34 patient entries did not have the disposition documented.

3. Interviews
During an interview conducted on 1/20/11 at 10:20 AM with Employee Identifier #1, the Chief Clinical Officer, verified the ER log was incomplete.

4. Immediate Interventions
On 1/202011, the facility began inservicing staff on the proper completion of the central log. The facility reports there will be daily monitoring by the charge nurse. The corrective action to be "overseen" weekly by the QA director.