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1. Based on review of the Medical Staff Rules and Regulations, policies and procedures and staff interviews it was determined the facility failed to ensure the hospital's Medical Staff Rules and Regulations and or policies and procedures defined that Advanced Registered Nurse Practitioners, Physician Assistants-Certified, Licensed Clinical Social Workers and Social Workers were qualified to conduct appropriate medical screening examinations that were within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists. Refer to findings in Tag A-2406.


2. Based on review of medical records, policy and procedures and staff interviews it was determined the facility failed to inform an individual acting on behalf of the patient of the risks and benefits to the individual of the examination and treatment; and failed to obtain a written informed refusal from the individual acting on the patient' s behalf for 1 (#9) of 42 sampled patient records. Additionally, the facility failed to ensure that documentation in the medical record contained a description of of the examination of the treatment or both for patient #9.

Based on review of the Medical Staff Rules and Regulations, policies and procedures and staff interviews it was determined the facility failed to ensure the hospital's Medical Staff Rules and Regulations and or policies and procedures defined that Advanced Registered Nurse Practitioners, Physician Assistants-Certified, Licensed Clinical Social Workers and Social Workers were qualified to conduct appropriate medical screening examinations that were within the capability of the hospital's emergency department to include ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists.

Findings were:

1. Medical Staff Rules and Regulations
John Hopkins All Children's Hospital, Inc., (JHACH), Medical Staff General, and Subject: Medical Staff Rules and Regulations, Policy Number MEDSTF002, Effective Date: 4/19/2018, Version 11.0 was reviewed. The section titled, Patient Care revealed in part, "L. Performance of Medial Screening Examinations-Physicians with appropriate privileges may perform a medical screening examination (MSE) of an individual who comes to the emergency department in order to determine whether the individual has an emergency medical condition." The review revealed that Advanced Registered Nurse Practitioners, Physician's Assistant- Certified, Licensed Clinical Social Workers and Social Workers randomly performed medical screening examinations and were not defined in the Medical Staff Rules and Regulations and Policy and Procedure as Qualified Medical Providers.

2. Policy and Procedure
The facility's policy titled "John Hopkins All Children's Hospital, Inc. Patient Care Administrative General: Subject Emergency Medical Treatment and Labor Act (EMTALA) & Patient Evaluation, Treatment or Transfer to Other Hospitals, Policy Number: PTCRE014; Effective Date: 10/30/2017, Version 1.0 was reviewed. The policy revealed in part, "V. PROCEDURE: ...D. After triage, all patients shall receive a medical screening examination by a qualified medical personnel to determine whether the patient has an emergency medical condition. The qualified personnel at JHACH will be a physician."

3. Interviews

An interview was conducted with the Director of the ED on 1/10/2019 at 9:00 a.m., she stated that Psychosocial assessments are completed by the Social Workers. The surveyor requested to review a list individuals who have been determined qualified and approved by the board to perform medical/psychiatric screening examinations. She stated that she did not have a list of individuals who were qualified medical providers, besides the physicians who were approved by the board to conduct medical screening and psychiatric examinations.

Interviews were conducted with the RN (Registered Nurse) Senior Director Care Coordinator, Licensed Clinical Social Worker # 7 and #8 on 1/9/2019 at 9:40 a.m. The RN Senior Director Care Coordinator stated that Mental Health Assessments are completed by Licensed Clinical Social Workers (LCSW). She also stated that the LCSW collaborates their findings with the ED physicians. Licensed Clinical Social Workers #7 and #8 stated that an ED physician will do the medical screening examinations and assess the patient's psychiatric concerns. They both stated that their scope of practice allows the social worker to conduct the assessment of psychiatric patients. They stated that Social Services are consulted and conduct a thorough risk assessment and psychosocial assessment. They stated that after the psychosocial assessment is completed, the social worker goes back to the ED physician and they reach a final conclusion if the need arises the LCSW will complete the BA (Baker-Act) form. If we are not in agreement and need additional support we have collaborative conversations, with the LCSW, Emergency Department Medical Doctors, and the psychiatrist on call. If we cannot come to a conclusion then the on-call psychiatrist has to come in and evaluate the patient.

An interview was conducted with the Medical Director of the Emergency Department on 1/10/2019 at 2:00 p.m. He stated that medical screening examinations are conducted by the PA-C's and the Emergency Department physicians. He stated that the Nurse Practitioner or the PA-C does the initial assessment, and discuss the work-up with with the ED physicians.

Based on review of medical records, policy and procedures and staff interviews it was determined the facility failed to inform an individual acting on behalf of the patient of the risks and benefits to the individual of the examination and treatment; and failed to obtain a written informed refusal from the individual acting on the patient' s behalf for 1 (#9) of 42 sampled patient records. Additionally, the facility failed to ensure that documentation in the medical record contained a description of of the examination of the treatment or both for patient #9.

Findings were:

The facility's Policy and procedure titled, Johns Hopkins All Children's Hospital, Inc. Patient Care/Administrative General: Subject: Emergency Medical Treatment and Labor Act (EMTALA) & Patient Evaluation, Treatment or Transfer to other Hospitals, Policy Number: PTCRE014, Effective Date: 10/30/2017, Version 1.0 was reviewed. The policy specified in part," V. PROCEDURE:... L. If the patient refuses any examination, treatment or transfer recommended by a treating physician, the nursing staff shall take reasonable steps to obtain the written acknowledgement of the patient/responsible person, documenting the examination, treatment, and/or services offered to the patient, the information given to the patient concerning the benefits of the offered services and risks of refusal, and the patient's refusal to accept examination, treatment or transfer recommended (Use Refusal of Treatment Form), The medical records must contain a description of the examination, treatment that was refused by or on behalf of the patient."

The electronic medical record for patient #9 was navigated through by an ED staff member for the surveyor to review. The review of the electronic medical record revealed that patient #9 was 5 months old and presented to the ED with his mother on 1/1/2019 at 8:01 p.m. The triage nurse documented the patient's vital signs were: Rectal temperature: 37.9 degrees Centigrade (Converted to 100.2 degrees Fahrenheit); Pulse rate: 139; Respiratory Rate: 32; Blood Pressure: 104/66; Oxygen saturation-100% on room air. The patient's pain level was 0 (zero). The patient was triaged as an ESI-Level -4. The triage nurse documented the in part, "pt with cough and cold symptoms for the last 5 -6 days. Seen here and Dx (diagnosed)with cold but now his secretions are green. Mom concerned." The nurse also documented that patient #9 was alert and his breath sounds were clear and equal. Further review of the electronic record revealed the family member verbalized to the nurse that they were leaving. Interview on 1/9/2019 at 9:00 a.m. with the ED Senior Director and ED Clinical Manager verified that there was no documentation in the electronic medical record of the risks and benefits of the examination and/or treatment was explained to patient #9's mother on 1/1/2019.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to obtain written informed refusal of the examination and or treatment, and no documentation of a description of the examination or treatment that refused by the individual acting on patient #9's behalf on 1/1/19.