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Based on review of Medical Staff Bylaws and Rules and Regulations, hospital policy, and interview, it was determined North Alabama Medical Center failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) in the hospital medical staff bylaws or rules and regulations. This had the potential to affect all patients presenting to the emergency department (ED).

Refer to A2406 for findings.

Based on review of the hospital's Rules and Regulations of the Medical Staff, Medical Staff Bylaws, hospital policy and interview, it was determined the hospital failed to identify the Qualified Medical Personnel (QMP) determined qualified to provide an appropriate Medical Screening Exam (MSE) in their Rules and Regulations of the Medical Staff and/or Medical Staff Bylaws.

Findings include:

Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of Emergency Medical Conditions (EMC)
Policy Number: 14184194
Last Revised : 08/2023

Purpose:

To ensure that individuals...receive an appropriate MSE as required by...EMTALA.

Definitions:

...R. QMP means an individual other than a licensed physician who has demonstrated current competence in the performance of MSE's and been approved by the main hospital provider's governing board...The categories of non-physician practitioners who may be designated as QMP's is set forth in Medical Staff Bylaws or Rules and Regulations...

1. A review of the hospital's Rules and Regulations of the Medical Staff, and Medical Staff Bylaws conducted on 2/5/25 revealed there was no definition of the QMP approved to perform the MSE and determine whether or not an EMC existed for patients who presented to the Emergency Department (ED).

An interview was conducted on 2/5/25 at 3:15 PM with Employee Identifier # 1, ED Director, who confirmed the QMP approved to perform the MSE's in the ED were not defined in the hospital's Rules and Regulations of the Medical Staff nor the Medical Staff Bylaws.