HospitalInspections.org

Based on document review and interview, the facility did not comply with the requirements at 489.20 (l) and 489.24. Specifically, the facility lacked a policy and procedure (P&P) regarding EMTALA (Emergency Medical Treatment And Labor Act) and its requirements. Two of four staff lacked knowledge of what EMTALA is. Additionally, the facility's Medical Staff Bylaws/Rules & Regulations failed to identify qualified medical providers (QMPs) who perform a medical screening examination (MSE) for patients presenting to the Emergency Department (ED) to rule out an emergency medical condition (EMC) and/or a patient presenting to the Obstetrical (OB) Unit to rule out active labor (please reference findings at Tag 2406). This could lead to untoward patient outcomes.

Findings include:

-- Review of the emergency department's (ED) P&Ps revealed the facility lacked an EMTALA P&P.

-- Per interview of Staff A, Registered Nurse (RN) on 1/5/2022 at 11:05 am and 11:40 am, staff have access to a book about EMTALA (but didn't know where the book was presently located). He/she did not know the definition of EMTALA, stating "it has to do with violations and avoiding fines." Staff A stated he/she had not had any EMTALA training. During a follow up interview at 11:40 am, when asked if someone without insurance would be treated in ED, he/she indicated "yes, the hospital is good like that."

-- Per interview of Staff B, RN on 1/5/2022 at 3:45 pm, EMTALA is a guideline used when it's appropriate to transfer a patient.

-- Per interview of Staff C, RN, Clinical Information Liaison on 1/5/2022 at 2:30 pm, there is not annual EMTALA training for employees. A new RN in the ED receives EMTALA training as part of their orientation.

-- Per interview of Staff D, Chief Operating Officer on 1/5/2022 at 3:45 pm, the facility provides EMTALA education and a "Transfer out of Facility" checklist at the time of employee orientation. He/she acknowledged the above findings.

Based on document review and interview, the facility failed to identify qualified medical providers (QMPs) who perform a medical screening examination (MSE) for patients presenting to the Emergency Department (ED) to rule out an emergency medical condition (EMC) and/or a patient presenting to the Obstetrical (OB) Unit to rule out active labor in their bylaws. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's "Bylaws of the Medical Staff," dated 2016, indicated in "Article XV: Rules and Regulations," patient management will be accomplished per medical staff policy.

-- Per review of the facility's policy and procedure (P&P) titled "Medical Staff: Emergency Department Care," dated 5/2021, all persons presenting to the ED for care shall be given a MSE by a qualified member of the medical staff to establish whether active labor or an EMC exists. The P&P did not identify QMPs other than medical staff.

-- Per interview of Staff D, Chief Operating Officer on 1/6/2022 at 1:00 pm, senior registered nurses (RNs) from the OB unit (OB unit currently not open) were performing vaginal exams on patients to rule out active labor and notifying the physician of their assessment which would identify them as a QMP. Going forward when the OB unit opens this practice will continue. He/she acknowledged the above findings.