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Based on document review and interview the facility failed to ensure the Medical Staff Bylaws included a statement of privileges that allowed 1 of 1 (Nurse Practitioner #3) to complete a Medical Screening Exam in 5 of 18 (Patient #9, #13, 15, #18, and #21) patient medical records reviewed. Also, the facility failed to follow the policy titled, "EMTALA".


Findings:

A review of medical records was completed with Director of Nurses (DON) Registered Nurse (RN) Staff #2 on 11/05/2024 after 10:00 AM. The review revealed the following.

Patient #9
Patient #9 was a 69-year-old female who presented to the Emergency Department (ED) on 11/02/2024 at 7:02 PM with a finger laceration. She was triaged by Registered Nurse (RN) #19 on 11/02/2024 at 7:17 PM and taken to ED Room #01.

The MSE was completed by Nurse Practitioner (NP) #3 on 11/02/2024 at 8:03 PM. Patient #9 was examined, treated, and discharged home by NP #3.

Patient #9 departed the facility on 11/02/2024 at 8:31 PM without having an MSE from a qualified medical provider.


Patient#13
Patient #13 was a 28-year-old male who presented to the ED on 11/02/2024 at 11:07 AM with a chief complaint of head laceration. He was triaged by RN #6 on 11/02/2024 at 11:09 AM and taken to ED Room #6.

The MSE was completed by NP #3 on 11/02/2024 at 11:13 AM. Patient #13 was examined, treated, and discharged home NP #3.

Patient #13 departed the facility on 11/02/2024 at 1:35 PM without having an MSE from a qualified medical provider.


Patient #15
Patient #15 was a 79-year-old female who presented to the ED on 11/01/2024 at 7:12 PM with a chief complaint of a laceration to the right lower leg. She was triaged by RN #18 on 11/01/2024 at 7:15 PM and taken to ED Room #6.

The MSE was completed by NP #3 on 11/01/2024 at 7:22 PM. Patient #15 was examined, treated, and discharged home by NP #3.

Patient #15 departed the facility on 11/01/2024 at 8:36 PM without having an MSE from a qualified medical provider.


Patient #18
Patient #18 was a 24-year-old male who presented to the ED on 11/04/2024 at 12:26 PM with a chief complaint of abdominal pain. He was triaged by RN #5 on 11/04/2024 at 12:29 PM and taken to ED Room #4.

The MSE was completed by NP #3 on 11/04/2024 at 12:26 PM. Patient #18 was examined, treated, and discharged home by NP #3.

Patient #18 departed the facility on 11/04/2024 at 2:28 PM without having an MSE from a qualified medical provider.


Patient #21
Patient #21 was a 65-year-old female who presented to the ED on 11/04/2024 at 8:58 PM with a chief complaint of left shoulder pain, right elbow pain, right knee pain, and laceration to her lip after a fall at her home. She was triaged by RN #21 on 11/04/2024 at 9:15 PM and taken to ED Room #4.

The MSE was completed by NP #3 on 11/04/2024 at 9:41 PM. Patient #21 was examined, treated, and discharged home by NP #3.

Patient #21 departed the facility on 11/04/2024 at 11:15 PM without having an MSE from a qualified medical provider.



A review of the Medical Staff Bylaws & Rules and Regulations revised January 2023 was as follows;

" ...A. Admission and Discharge of Patients ...

B: Emergency Services:

1. The Medical Director shall have overall responsibility for emergency care for patients. The Hospital provides first aid and referral for emergencies.
a ...
b ...
c ...
d. The policies and procedures governing emergency medical care shall be established by and shall be a continuing responsibility of the Medical Staff.
e ...
f. Medical Screening examinations will be performed by qualified RN's under the supervision of a qualified Member of the Medical Staff ..."



A review of the facility policy titled, "EMTALA", with an effective date of December 9, 2019, was as follows:
"PURPOSE: To ensure that Lumberton Hospital LLC. complies with the requirements of the
Emergency Medical Treatment and Active Labor Act (EMTALA') and associated regulations (42 U.S.C.1395dd and 42C.F.R. 489.20.-24). To be in compliance with Texas Licensing Regulation 133.163.

POLICY: It is the policy of the Altus Lumberton Hospital that all patients requesting emergency services receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act ("'EMT ALA"), 42 U.S.C., Section 1395 and all Federal regulations and interpretive guidelines promulgated there under ...

PROCEDURE:

MEDICAL SCREENING EXAMINATION: All patients who come to Altus Lumberton
Hospital for emergency medical treatment shall receive an appropriate Medical Screening
Examination (MSE). Neither the MSE nor necessary stabilizing treatment shall be delayed in
order to inquire about an individual's method of payment, and insurance status, or in order to obtain prior authorization ...

1 ...
2 ...
3 ...
4. Personnel Qualified to Perform the Exam

a) Qualified Medical Person at Emergency Department means physician in the hospital ..."


An interview was conducted with Nurse Practitioner (NP) #3 on 11/05/2024 after 11:00 AM. NP #3 was asked if he completed the MSE on the ED patients. NP #3 stated, "Yes, I do".

An interview was conducted with Chief Nursing Officer (CNO) Staff #1 on 11/06/2024 after 10:00 AM. CNO Staff #1 was asked who was considered a qualified RN as stated in the Medical Staff Rules and Regs dated 2023. CNO Staff replied, "I would say that refers to Nurse Practitioners". CNO Staff #1 was asked if the Medical Staff Rules and Regs defined a Qualified RN. CNO Staff #1 confirmed the Medical Staff Rules and Regs did not define a qualified RN.



A review of the Governing Body meeting minutes dated January 2024 revealed the Medical Staff Bylaws & Rules and Regulations had been reviewed but there was no approval of the revised rules documented.

In an interview on 11/06/2024 after 10:00 AM with CNO Staff #1, CNO Staff #1 was asked if the Medical Staff Bylaws & Rules and Regs had been approved. CNO Staff #1 stated, "No, this is all I have. I do not have anything saying they were approved. CNO Staff #1 confirmed 5 of 18 (Patients #9, #13, 15, #18, and #21) patients reviewed had received an MSE by a non-qualified individual".

Based on observation, document review, and interview the facility failed to ensure the required signage (per Section 1867 (a)(1)(N)(iii) of the Social Security Act) specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX) was posted conspicuously for all patients entering the Emergency Department (ED) for health care services.


Findings:

A tour of Facility #2 was conducted on 11/06/2024 at 8:33 AM with Registered Nurse (RN) Staff #15. While observing the main lobby of the Emergency Room (ER) at Facility #2, the surveyor did not observe the required signage posted in the patient waiting area.

An interview was conducted with the Chief Nursing Officer (CNO), Administrator Staff #1 on 11/06/2024 after 9:00 AM. Staff #1 confirmed Facility #2 failed to display the required signage specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMC), women in labor, and whether or not the hospital participated in the Medicaid program under a State plan (under Title XIX).