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2400 Based on review of review of facility Medical Staff Rules and Regulations, Emergency Center/Emergency Department Policy and Procedures, job description, and interview, the hospital ' s Evaluation Center/ Emergency Department (EC/ED) failed to ensure consistent implementation of the facility policy and procedure relative to who is designated and qualified to perform medical screening examinations, as set forth in the approved Medical Staff Rules and Regulations. This deficient practice has the potential to affect patients presenting to the EC/ED. Refer to findings in A2406.

2406 Based on review of the hospital's Medical Staff Rules and Regulations, Emergency Center/Emergency Department (EC/ED) policies and procedures, job descriptions and staff interview, the hospital failed to ensure that approved Medical Staff Rules and Regulations were consistently followed as to who was clearly delineated and designated as qualified to perform medical screening examinations. This deficient practice has the potential of affecting any patient presenting to the EC/ED for emergency services. Findings Include: 1. Review of the Hospital's Medical Staff Rules and Regulations (Approved 11/29/09) includes: "...General Medical Staff 2/9/10...7.0 Emergency Department/Evaluation Center... 7.1 Physician Requirements: ...A Licensed Independent Practitioner (LIP) or a Certified Registered Nurse Practitioner (CRNP) with appropriate clinical privileges will assess the patients in need of emergency care and determine appropriate management. The CRNP must review all cases with the LIP and the LIP must sign the patient's medical record..." 2. The EC/ED Policies and Procedure entitled EMTALA (Cobra) Transfer Policy, City-Wide (Reviewed 4/09, Revised 6/10) was reviewed. The policy indicated in part, "...Medical Screening Examination Policy:...A registered nurse may perform the medical screening exam to ascertain emergency medical condition...If an emergency condition exists, a chart documenting findings shall be initiated. B. Medical Screening Examination Procedure: A qualified medical person, either a registered nurse or physician shall: 1. Conduct medical screening examination upon arrival...- If a patient or a person acting on the individual's behalf of risks of refusal or the proposed examination or treatment and of the potential benefits. - Document steps taken to secure written refusal in the medical record or...Against Medical Advice..." 3. Review of the ED/EC Policy and Procedure entitled Triage Classification (original date 7/06, revised 8/06) includes: "...1. Policy: All patients presenting to the EC [Evaluation Center] will be triaged and the RN will determine the priority of care based on physical, developmental and psychosocial needs as well as factors influencing access to healthcare and patient flow through the emergency care system. II. Procedures: A. The nurse will perform a rapid systematic collection of data relevant to each patient's chief complaint.... D. There will be four acuity classifications: 1. Class I: Emergent a. Definition: Unstable with the potential loss of life or limb. These patients require immediate attention. b. Treatment: The patient will be taken directly to a treatment room and a physician will be summoned for immediate exam. 2. Class II: Urgent a. Definition: These patients have a potentially critical condition, which may worsen if not treated promptly. b. Treatment: Triage sheet and vitals are completed at triage. The patient is placed in the first available room and will be examined by the first available physician. 3. Class III: Non-urgent a. Definition: Symptoms are not life threatening that could potentially be treated in a physician's office. b. Treatment: Triage sheet and vitals are completed at triage. 4. Obstetrics a. Definition: Pregnant patients that are over 20 weeks gestation or any pregnant patient presenting with a actual/potential life threatening complaint for either fetus or self. 4. The hospital's "Job Description...Present Job Title RTN [Registered Training Nurse]...Original 3/6/01, Revised 8/16/2004..." includes: " ...ESSENTIAL JOB FUNCTIONS:...documentation responsibilities..." includes: 1. Maintains accurate and complete medical records by: Utilizing the correct documentation and procedures. Triage sheet complete within unit timeframe, Evaluation Center chart, and flow sheet complete with signature Discharge form complete Pain Assessment tool complete Transport Flow sheet Supervising, evaluating and finalizing the patient care record ... The Registered Nurse responsibilities for all unit specific care: 1. Completes triage course after 6 months of Emergency Nursing experience. 2 . Prioritizes and classifies patient conditions appropriately in triage. 3. Maintains an orderly environment in triage and waiting area. 4. Administers appropriate patient care in all emergency situations. 5. Demonstrates effective time management when providing patient care in a stressful environment. 6. Completes PALS and ACLS within 1 year of employment. 7. Provides on call support to unit when Pediatric Critical Care Transport Team is dispatched. 8. Maintains current knowledge base of all unit policies and procedures, equipment location and supplies. 9. Administers and monitors conscious sedation..." There is no mention of the RTN performing medical screening examinations in the EC/ED. 5.. Interview: On 8/2/2010 at 12:55 PM, during the entrance conference Hospital #1's Administrator (Employee Identifier Number One (EI #1) was asked who can perform the medical screening exam, EI# 1 stated all of the hospital's registered nurses (RN's) are training nurses and all are qualified to do medical screening examinations, and this is in the EC/ED policies. The facility failed to ensure that hospital policies and procedures are consistent with the Medical Staff Rules and Regulations relative to who is designated and qualified to perform medical screening examinations. This citation is written as a result of the investigation of complaint AL00023009.