HospitalInspections.org

Based on review of Medical Staff Bylaws, Hospital Bylaws, and staff interviews, the hospital failed to comply with all requirements of 489.24.

Refer to citation at:
A 2406 (489.24(c)) Medical Screening Exam - a. The Bylaws did not contain language that specified which medically qualified personnel had been determined qualified and approved by the Governing Body to conduct emergency medical exams.

Based on review of the hospital's by-laws and staff interviews, the hospital failed to have language in by-laws, approved by the Governing Body, that specified which medically qualified personnel had been determined qualified to conduct emergency medical exams (MSEs).

Findings:

Interview of ED and obstetrical staff and RNs, and review of staff training files on January 5, 2016 showed that ED physicians performed medical screening exams for ED patients, and obstetrical department RNs performed medical screening exams for pregnant women at greater than 20 weeks gestation who came to the ED for medical care. Review of staff training files showed that OB RNs were trained and competent to perform the MSEs for pregnant women.

Review of hospital's by-laws failed to evidence that the Governing Body had identified and approved which qualified medical personnel were approved to conduct Medical Screening Exams. Staff interviews on January 5, 6 and 8, 2016, verified that comparable language did not exist in current hospital or medical staff bylaws.