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Based on review of Medical Staff Bylaws, Rules and Regulations, policies and procedures, medical record reviews, and interviews, it was determined the facility failed to ensure that an appropriate medical screening examination was conducted for 1 of 10 sampled patients. Additionally, the facility failed to include in their Medical Staff Bylaws and Rules and Regulations that Physician Assistants and Nurse Practitioners were qualified and eligible to perform Medical Screening Examinations (MSE) in the Emergency Department. Ten of 10 (#1 through 10) non-physician practitioners files were reviewed and indicated that they were not eligible to conduct Medical Screening Exams according to the Medical Staff Bylaws. This affected 1 of 20 (Patients # 1) sampled patients reviewed who presented to the Emergency Department for treatment.

The findings included:

1. On 10/18/10 at 1:50 PM, the Administrative Assistant presented the Medical Executive Minutes dated 1/10/06 recommending Physician Assistants [PA] and Nurse Practitioners [NP] to be allowed to perform Medical Screening Examinations [MSE] in the Emergency Department [ED]. Board of Trustees minutes dated 1/17/06 documented Board approval of the recommendation.

2. Review of the Medical Staff Bylaws dated December 15, 2009 revealed Article XX of the Bylaws titled Rules and Regulations documented on page 72, "All persons seeking emergency services and care will receive a medical screening examination and evaluation by a physician or a qualified medical person as designated by hospital policy." The Bylaws failed to indicate that PA's and NP's were eligible for credentialing in order to provide MSE's in the ED.

3. During an interview on 4/22/10 at 11:30 AM, the Medical Staff Coordinator confirmed the use of a PA's and NP's to conduct MSE was not included in the Medical Staff Bylaws.
Additionally, during an interview on 10/18/10 at 11:40 AM, the Medical Staff Coordinator stated the Bylaws did not include a statement that non-physicians could perform MSE's and would never include that statement.

4. During an interview on 10/18/10 at 11:39 AM, the Quality Director verified the facility Medical Staff Bylaws did not specifically document that PA's and NP's were allowed or eligible to perform MSE's.

5. Review of credential files revealed Non-Physician Practitioners were approved by the Board of Trustees to work in the ED and to perform MSE's as of 4/23/10, however they were not privileged to conduct Medical Screening Examinations. Even though they were approved and credentialed to perform the Medical Screening Exams by facility Policy and Procedure, the Medical Staff Bylaws failed to indicate that the PA's and the NP's were eligible for credentialing to perform this function. The Medical Staff Bylaws failed to include the titles of professional staff members qualified to perfom Medical Screening Exams. The facility's Policies and Procedures could be amended and revised without the approval of the Medical Staff. The following include a list of those Non-Physician Practitioners who were approved to perform Medical Screenings, however were not eligible:

a) Non-Physician Practitioner #1, a PA, was originally credentialed for the ED on 6/19/07. The reappointment dated 6/16/09 included approval to perform MSE's.
b) Non-Physician practitioner #2, a NP, was originally credentialed on 2/20/01. The reappointment dated 6/16/09 included approval to perform MSE's.
c) Non-Physician Practitioner #3, a PA, was credentialed for the ED on 2/16/10. The appointment included approval to perform MSE's.
d) Non-Physician Practitioner #4, a PA, was originally credentialed for the ED on 2/19/08. The reappointment dated 6/16/09 included approval to perform MSE's.
e) Non-Physician Practitioner #5, a NP, was originally credentialed for the ED on 12/18/07. The reappointment dated 6/16/09 included approval to perform MSE's.
f) Non-Physician Practitioner #6, a PA, was originally credentialed for the ED on 2/19/08. The reappointment dated 6/16/09 included approval to perform MSE's.
g) Non-Physician Practitioner #7, a PA, was originally credentialed on 9/21/03. The reappointment dated 6/16/09 included approval to perform MSE's.
h) Non-Physician Practitioner #8, a PA, was credentialed for the ED on 8/28/09. The appointment included approval to perform MSE's.
i) Non-Physician Practitioner #9, a NP, was credentialed for the ED on 4/28/09. The appointment included approval to perform MSE's.
j) Non-Physician Practitioner #10, a NP, was originally credentialed for the ED on 2/19/08. The reappointment dated 6/16/09 included approval to perform MSE's.

6. Medical record review revealed Patient #1, who was uninsured, was seen in the ED on 3/23/10 with arrival time documented as 1759. A handwritten note on the "Sign-In Sheet for Emergency Services" form documented the patient came to the Emergency Department because of, "Pain when breathing/upper right side." Triage performed by a Registered Nurse (RN) at 1805 documented the reason for the patient's visit was "Right rib pain." Temperature was 98.6 orally, pulse 86, respirations 20, Blood Pressure 121/73 and Oxygen Saturation 99%. The Triage level assigned was Level 4 [Non-urgent]. A MSE was performed at 1815 by Non-Physician Practitioner #8 who determined the patient did not have an emergency medical condition and that the Clinical Impression was a "cough and back pain." The Emergency Department Information Sheet dated 3/23/10 at 1826 indicated that the patient did not have an emergent condition that requires emergency room care and gave the patient the option to follow up with a community resource. Patient #1 did not sign this form. The form was signed by a witness who indicated that the patient "refused to sign". It was documented that the patient left the facility on 3/23/10 at 1826.

The emergency room record documented that the patient had a sharp pain upon inspiration with associated cough, and that patient had a mild Upper Respiratory Infection in the past week. There was no evidence of any Physician orders or that a chest x-ray was completed. The patient left the facility on 3/23/10 at 1826. The facility failed to ensure that an appropriate Medical Screening Examination was conducted for Patient #1 on March 23, 2010.

Patient #1 presented to another hospital on 3/23/10 at 1957 with complaints of pain in back/shoulder/chest when taking breaths. The patient received a chest -ray, albuterol/atrovent, chest CT with IV contrast, pain medication and antibiotics. The chest x-ray and CT of the chest confirmed that there was infiltrate in the right upper lobe. Patient #1 clinical impression was Pneumonia. Patient was discharged at 0030 from this second hospital.