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Based on review of records and interview, the facility failed to identify individuals who were qualified to perform the Medical Screening Examination (MSE) in the Medical Staff Bylaws or Rules and Regulations.

Findings were as follows:

On 4-30-2018, a review of Emergency Department staffing showed that mid-level providers were used in the Emergency Department (ED). Staff #4 confirmed that the physician on duty provided the MSE for patients that were assigned to the physician. The mid-level providers conducted the MSE for the lower acuity patients that were assigned to them.

On 4-30-2018, Staff #8, a Family Nurse Practitioner (FNP), was on duty in the ED. A review of Patient #23 and Patient #24 charts revealed that Staff #8 provided the MSE, treated, and discharged the patients.

Review of the Medical Staff Rules and Regulations dated June 27, 2017; Section X: General Rules Related to Emergency Services; page 35, item H. was as follows:

"H. Any patient presenting to the Emergency Department shall have a Medical Screening Examination performed by a physician or other qualified medical personnel (QMP) based on their conditions, complaints and history. For pregnant women having contractions, this will include at a minimum on-going fetal heart tone assessment, observation of the regularity and duration of uterine contractions, fetal position and station and cervical dilatation and status of membranes. If the Medical Screening Examination reveals a medical condition of sufficient severity such that the absence of immediate medical attention could be reasonably expected to result in placing the health of the individual in serious jeopardy, result in serious impairment of bodily functions or result in serious dysfunction of any organ, then further stabilization and treatment is to be provided regardless of financial considerations or insurance coverage. If the Medical Screening Examination does not reveal such a medical condition, the patient can be advised on available appropriate care. For pregnant patients found to be in false labor, qualified medical personnel, defined by the OB/GYN Department to be registered nurses who have received special training, may provide an assessment of the patient to the physician (including over the telephone) and the physician may then make the determination that the patient is in false labor. The physician must then countersign the medical record to document this determination."

Review of EMTALA- Medical Screening Exam and Stabilization Policy, last reviewed by the hospital on 1/30/2018, was completed. The policy did not match what was in the Medical Staff Bylaws, Rules & Regulations. The policy was as follows:

"A. When a Medical Screening Examination (MSE) is required - an individual must receive an MSE within the capabilities of the hospital's dedicated emergency department (DED), to determine whether or not an emergency medical condition (EMC) exists, and whether or not the treatment requested is explicitly for an emergency condition.

With respect to a pregnant woman having contraction, a MSE will be provided by a qualified Obstetric practitioner to determine whether the woman is in labor. Qualified Obstetric Practitioner may include a Physician, Physician Assistant (PA), Advanced Practice Nurse (APN) or a Registered Nurse (RN) who is educated in and demonstrates current competency in obstetric nursing, and the nurse's education and competency skills are documented in facility records on an ongoing basis. The RN must communicate with the attending physician APN or PA via telephone, email or other appropriate means to report the assessment and physical findings and obtain an order from the attending provider to either admit or discharge the patient following the assessment.

Under most instances, the MSE of a pregnant woman who is having contractions will be accomplished by monitoring her on the HRMC Labor & Delivery (L&D) department for the length of time established by the L&D department policy and procedure, (generally 2 hours). The assessment must include at a minimum, ongoing evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation and status of membranes.

A woman experiencing contractions in in true labor unless a QMP determines, and certifies in writing, that she is in false labor. If the MSE rules out false labor, then the woman will remain at HRMC until after the fetus and placenta are delivered, and her condition and the condition of the newly delivered infant are medically stable, unless her condition or the condition of the fetus are determined to be of such complexity that HRMC does not have the necessary expertise and ability to safely deliver her, and failure to transfer would result in deterioration of her condition or the fetus's condition."

Interview with Staff #2 was done on 5-30-2018. Staff #2 stated the policy was a compliance policy that went through the compliance committees, but did not go through Medical Executive committees.

No further definition or identification of Qualified Medical Personnel allowing a Nurse Practitioner to provide the MSE in the ED was found or provided by the facility.