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|ST FRANCIS HOSPITAL||241 NORTH ROAD POUGHKEEPSIE, NY||Sept. 12, 2013|
|VIOLATION: EMERGENCY ROOM LOG||Tag No: A2405|
|Based on a review of the facility's Emergency Department Electronic Daily Log (Central Log), medical record review, and staff interview, it was determined that the facility failed to maintain a complete and accurate Central Log. This was evident in 8 of 22 medical records reviewed. MR#1, MR#2, MR#3, MR#4, MR#5, MR#6, MR#7 and MR#8.
The emergency room Log for June 1, 2013 to August 26, 2013 was reviewed from August 22, 2013 to August 26, 2013.
MR#7, the patient was brought to the emergency department on July 24, 2013 for alcohol intoxication and a fall. Documentation in the medical record indicated that at "19:00 hours, the patient went to the bathroom and did not return"...."Patient absconded from the emergency room . Police notified". Documentation in the Central Log stated that the patient Left Against Medical Advice.
MR#8, the patient presented to the emergency department with "altered mental status" on July 26, 2013 at 23:04. On July 27, 2013 at 0:45, the patient "ran out of the Medical emergency room . Police called". A review of the Central Log reflected that the patient Left Against Medical Advice.
MR#1, the patient presented on July 20, 2013 with a chief complaint of flank pain. A medical screening examination was completed by the physician. According to the emergency room record, on July 21, 2013, the patient "pulled out IV and left the ER before results were available". Documentation in the Central Log reflected that the patient Left against Medical Advice.
Staff #1 the Chief Quality Officer, Staff #2, the Interim Nurse Manager for the emergency room , and Staff #3, the Director of Surgical Services / the emergency room , were interviewed on August 27, 2013 at 2:30 p.m. During an interview with the facility's staff it was revealed that they were not aware of the discrepancy between the documentation in the medical records and the Central Log.
The Administrative staff members #1, #2, and #3 stated that there appears to be " a glitch " in the emergency room 's computer system that does not allow the staff to input walk outs or elopements.
Quality Improvement Minutes for the emergency room , for the past three months were reviewed on August 26, 2013 at 2:30 p.m. There was no documentation in the Quality Improvement Minutes that the hospital was aware that the Central Log was inaccurate, or that the Quality Improvement Committee was tracking or addressing what is documented in the Central Log.
Similiar findings were found in MR #2, 3, 4, 5, and 6.