HospitalInspections.org

Based on record review and interview the hospital failed to adopt policies and procedures to ensure compliance with the requirements of EMTALA (Emergency Medical Treatment and Labor Act).

This failed practice had the potential for hospital staff, including medical staff to be unaware of their responsibilities under the EMTALA requirements.

Findings:

Review of document titled "Rules & Regulations Medical Staff" (revised 6/2011) showed no evidence of the EMTALA requirements for medical staff including but not limited to: physician on-call, medical screening examination (MSE), who is qualified to complete the MSE, emergency medical condition (EMC), necessary stabilizing treatment, appropriate in and out transfers, and whistleblower protection.


Review of policy titled "EMTALA Guidelines for Emergency Department Services" showed evidence of EMTALA requirements for MSE, defining EMC, physician on-call schedule and retention, stabilization and transfers. The policy failed to contain guidelines regarding EMTALA signage, retention of transfer records and whistleblower protection.

On 10/31/17 at 2:00 pm, Staff G stated he/she reviewed the Medical Staff Rules and Regulations and does not see any components of the EMTALA requirements in the document.

On 10/31/17 at 2:30 pm, Staff A stated he/she reviewed the "EMTALA Guidelines for Emergency Department Services" and it did not have EMTALA requirements for signage, transfer record retention and whistleblower protection.