Based on document review, medical records (MR) review, and interview, in 1 of 30 encounters, the facility failed to maintain a central log on all patients who present to the Emergency Department (ED). The failure to record patient encounters has the potential to cause delays in emergency care. Findings include: Review of facility Emergency Department Central Log had no documented evidence that Patient # 1 was entered in the facility data based system for registration on October 16th, 2017. On 10/25/17, at 12:00 PM, during an interview with staff D (RN ED Manager) she stated, "all patients who come into the ED are greeted by the clerk who obtains name of the patients, date of birth, and chief complaint after which the patients are immediately taken to the ED." During interview on 10/25/2017, at 12:00 PM, Staff F (RN ICU Manager), confirmed that this patient was not entered into the ED log, was not registered, and was not triaged. Review of the policy titled "Health Information Management Services", (reviewed: 11/2016) states that when a patient seeks emergency care, "the registrar will perform a "'quick-reg'" during which basic information about the patient is collected such as name, date of birth, and chief complaint so the electronic medical record can be initiated for medications, diagnostics and documentation. This patient (#1) was not registered and a medical record was not initiated.

Based on interview, medical record review (MR), and document review, in 1 of 30 encounters, the facility failed to perform a medical screening examination (MSE) for patient #l. This finding places patients at risk for serious harm and delays in emergency intervention. Findings: On 10/25/17, at 12:00 PM, during interview, Staff F (RN ICU Manager) stated: "on October 16, 2017, while performing the duties of an Emergency Department (ED) Nursing Supervisor, Staff E (Patient Registration Clerk) called me when Patient #1 came into the facility. The patient had presented the registrar with a prescription for transfusion of platelets and lab work results from another facility. The lab work results indicated that patient's platelets level is 13,000 per mcL (normal platelet count range is between 150,000 and 450,000 platelets per microliter or one-millionth of a liter). The patient requested a platelet infusion and said she had been unable to undergo the procedure at the facility, due to personal circumstances." Staff F further stated, "that the prescribing physician did not have privileges at the facility and the patient's physician is affiliated with Orange Regional Medical Center". The patient asked, "'what if I go to Orange Regional Hospital?'" Staff F answered that "this was her choice." The patient inquired about possible charges. Staff F stated that there might be some ED associated charges. She explained that the patient "can sign into the ED and would probably have to wait for a while because there are no platelets immediately available." Additionally, "type and cross would have to be performed and it would take a bit of time before the transfusion of platelets can be started." After the conversation, patient (#1) immediately left the facility. Staff F confirmed that patient #1 was not registered and did not receive an MSE. The facility failed to both triage and provide a medical screening examination to Patient #1. Therefore, the facility failed to follow EMTALA requirements for the provision of a medical screening examination.

Based on medical record review, document review, and interview, in one (1) of 14 medical records reviewed, the facility did not implement its policies and procedures to ensure that each patient presenting to the Emergency Department receives a comprehensive history and physical examination (Patient #1). Findings include: Review of the medical record for Patient #1 identified the following: On 6/24/16 at 2317 (11:17 PM), patient #1, a pediatric patient was seen in the Emergency Department (ED) with a primary complaint of a high temperature of 102.6 Fahrenheit (F) (Normal range 97 F to 98.9 F). The patient was assessed by the physician and the documentation noted that the skin was negative for color change and rash. A diagnosis of [DIAGNOSES REDACTED]. Patient #1 returned to the ED on 6/25/16 at 1557 (3:57 PM) with a temperature of 104 degree F. Another physician examined Patient #1 and noted; "Abrasion dorsum of R foot over an old abrasion with diffuse [DIAGNOSES REDACTED] and edema extending to the ankle." The Initial Physician Assessment in the ED on 6/24/16 at 2317 did not identify the changes in the patient's skin condition. Review of Medical Staff Bylaws, last reviewed on 1/2016, Section A, subtitle "History and Physical Examination" stated the following: " Physical Examination is to include inventory of the body system and vital signs." During interview with Staff J, Physician on 11/2/16 at 11:15 AM in the presence of Staff A, the Medical Director, he stated the child was very active, there was no suggestion of a limitation in movement, and he did not check for any condition in the patient ' s lower extremities. As a result of the lack of full assessment that includes the inventory of body systems, the presence of " Abrasion dorsum of R foot over an old abrasion with diffuse [DIAGNOSES REDACTED] and edema extending to the ankle" was missed and was not treated at the time of the first visit.