HospitalInspections.org

Based on review of the hospital's policies, Medical Staff Rules and Regulations, and Medical Staff Bylaws, as well as an informal interview with staff, it was determined that the hospital failed to formally identify in its bylaws or rules and regulations the individuals who were qualified to conduct a medical screening examination.

While on site, surveyors reviewed the hospital's Medical Staff Bylaws and Medical Staff Rules and Regulations. The review indicated that the hospital failed to formally identify in either of the documents the type of providers qualified to perform a medical screening examination as outlined in §489.24(a).

Review of several policies in the Emergency Department and the Labor and Delivery unit related to hospital obligations under EMTALA determined that the policies did not include a formal recognition of the individuals who were qualified by the hospital to perform a medical screening examination either.

During an informal interview with the Director of Accreditation on 01/16/2020, surveyors asked whether the hospital had any other policies which identified the personnel who was qualified to perform a medical screening examination. The Director answered that the hospital considered "History and Physical Examination" (H&P Exam) to be the same as the Medical Screening Examination, and that implied that the requirements for providers who could perform an H&P Exam were also qualified to perform a Medical Screening Examination. Additional review of the Medical Staff Bylaws revealed the following section: "Medical Staff Responsibilities. Histories and Physicals: The medical history and examination must be performed by a physician, an oral maxillofacial surgeon, or other qualified licensed individual in accordance with State law and hospital policy." The excerpt did not formally identify these individuals as qualified to perform a medical screening examination.