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Based on review of the hospital Medical Staff Bylaws and Rules and Regulations and interview with hospital leadership, it was determined the hospital failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations.

This deficient practice had the potential to affect all patients presenting to the hospital's emergency department requiring a MSE.

Findings Include:

Refer to A 2406 for findings.

Based on review of the hospital Medical Staff Bylaws and Rules and Regulations and interview with hospital leadership, it was determined the hospital failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Services in the hospital bylaws or rules and regulations.

This deficient practice had the potential to affect all patients presenting to the hospital's emergency department requiring a MSE.

Findings include:

The hospital's Medical Staff Bylaws (dated 1/25/2022) and Rules and Regulations (dated 1/23/2022) were reviewed on 10/16/23. The Medical Staff Bylaws and Rules and Regulations revealed no documentation to identify and approve the individual(s) qualified to perform the MSE for the hospital emergency services.

An interview was conducted with Employee Identifier # 1, Chief Executive Officer, on 10/16/23 at 4:54 PM who confirmed there was no documentation in the hospital bylaws or rules and regulations to identify and approve individual(s) qualified to perform the MSE.