HospitalInspections.org

Based on record review and interview, the governing board failed to establish who is qualified to perform a medical screening examination to meet the responsibilities of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in emergency cases in 3 of 3 of their governing policies and procedures (Medical Staff Bylaws, Medical Staff Organizational and Policy Manual and the Credentials Policy), the Emergency Department physician failed to perform a medical screening exam on 1 of 17 patients presenting to the Emergency Department with abdominal pain (Patient #1), and the hospital failed to provide EMTALA training to 2 of 4 Emergency Department staff working in the Emergency Department (Registered Nurse (RN) L, and Scribe H) in a total of 20 medical records reviewed.

Findings include:

The facility policies and procedures (Medical Staff Bylaws, Medical Staff Organizational and Policy Manual and the Credentials Policy) did not include expectations for the responsibilities of hospitals to meet EMTALA requirements. See A-2406

This facility failed to complete an appropriate medical screening exam (MSE) for 1 of 1 patient (Patient #1) who presented to the ED. See tag 2406.

The facility did not ensure that staff in the ED were trained in the responsibilities of hospitals to meet EMTALA requirements. See A-2406

Based on record review and interview, the governing board failed to establish who is qualified to perform a medical screening examination to meet the responsibilities of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in emergency cases in 3 of 3 of their medical staff governing policies and procedures (Medical Staff Bylaws, Medical Staff Organizational and Policy Manual and the Credentials Policy), the Emergency Department physician failed to perform a medical screening exam on 1 of 17 patients presenting to the Emergency Department with pain (Patient #1), and the hospital failed to provide EMTALA training to 2 of 4 Emergency Department staff working in the Emergency Department (Registered Nurse (RN) L, and Scribe H) in a total of 20 medical records reviewed.

Findings include:

Record review of the Medical Staff Bylaws, the Medical Staff Organizational and Policy Manual, and the Credentials Policy approved by the Board of Directors 9/01/2020, failed to designate who is qualified to complete a medical screening examination to meet the responsibilities of the EMTALA regulations in emergency cases.

On 11/08/2022 at 1:11 PM during interview with Quality and Risk Management Director E and the Vice President (VP) of Nursing Services F, when questioned where the facilities expectations were regarding the EMTALA regulations, Quality Director E confirmed it was not addressed in the Medical Staff Bylaws, the Medical Staff Organizational and Policy Manual, or the Credentials Policy. VP F confirmed the EMTALA regulations were not addressed in their contract with their ED providers.

On 11/09/2022 at 2:48 PM during interview with Medical Staff Coordinator M, Coordinator M stated "no" the medical staff providers do not get any orientation of the facilities expectations on the EMTALA regulations during orientation and confirmed their were no other policies or procedures that address EMTALA regulations or who is qualified to do a medical screening examination responding "don't they learn that in school?"

Record review "EMTALA & Transfer Policy," #0200-044 effective 8/17/2021 under Definitions revealed ""Medical Screening Examination" means an examination performed by a licensed physician or practitioner to determine with reasonable clinical confidence whether an emergency medical condition exists." Under policy revealed "the Hospital shall not discriminate against any individual because of diagnosis... or handicap." Under procedure revealed "The Hospital is required to perform a medical screening examination to the extent required to determine that the individual does not have an emergency medical condition."

Record review of policy "Pain Management" effective date 12/23/2019 under assessment revealed "The RN and/or provider will conduct a comprehensive pain assessment if the patient is having pain to determine a plan for pain management."

Record review of the facilities EMTALA education titled "EMTALA Emergency Medical Treatment and Labor Act", not dated under slide titled "Medical Screening Exam and Transfers" revealed "We must provide a medical screening exam for every patient."

Patient #1's medical record revealed Patient #1 is a 17-year-old with a history of autism, who presented to the Emergency Department on 8/22/2022 at 10:49 AM with guardian A, with a chief complaint of abdominal pain. Pain assessment completed 8/22/2022 at 11:17 AM was 8 using the FLACC Pain Scale, a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain, with 1 being relaxed and comfortable 10 being severe discomfort/pain. ED note dated 8/22/2022 at 12:01 PM by Physician B, electronically signed by Physician B on 8/22/2022 at 1:01 PM and 6:49 PM revealed "I, [scribe H], am serving as a scribe to document services personally performed by [Physician B] based on my observations and the provider's statements to me." Under history of present illness revealed "presents to the emergency department for evaluation of abdominal pain." Under Physical Exam revealed "Physical exam somewhat limited due to [guardian A's] escalating verbal tirade and inappropriate behavior here in ED." Under gastrointestinal findings revealed "Normal appearing." There was no gastrointestinal or abdominal assessment documented. ED nursing note dated 8/22/2022 at 1:01 PM by RN K revealed "Patient did have increase in vocalizations and whimpering during ambulation to the exit... plans to follow up with a different provider for lab work later today."

On 11/08/2022 at 12:23 PM during interview with Scribe H, Scribe H stated Physician B "didn't do a physical assessment" and stated Physician B never touched patient #1 or got close to the bed stating, guardian A was between patient #1 and the door.

On 11/08/2022 at 3:12 PM during interview with RN Educator K, RN K stated s/he understood what EMTALA was, what a medical screening was, and stated Physician B had concern for Munchausen's syndrome by proxy and determined no further testing was needed. When asked if s/he witnessed Physician B do a medical screening exam, RN K stated "I feel like, yes" a medical screening was done by Physician B with the "scribe in the room.". RN K stated "I wasn't sure what else we would do."

Record review of personnel files and training's revealed RN L was a contracted traveler nurse who started her contract on 7/05/2022. There was no documentation that RN L received the facilities expectations on EMTALA regulations.

On 11/09/2022 at 3:30 PM during interview with ED Director C, C stated "I'm not sure how that got missed" and confirmed they had no documentation of RN L's EMTALA training.

Record review of personnel files and training's revealed Scribe H was a contracted staff with the ED provider group and started 11/09/2021. There was no documentation that Scribe H received the facilities expectations on EMTALA regulations.

On 11/09/2022 at 1:45 PM during interview with ED Director C, C stated s/he called the ED contracted services office and confirmed there was no documentation that Scribe H received any training on the EMTALA regulations.