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Based on review of medical records (MR), Medical Staff General Rules and Regulations, facility policy, and interviews with staff, it was determined the facility failed to ensure a Medical Screening Exam (MSE) was performed by a provider who was designated as qualified in the Medical Staff General Rules and Regulations to perform a MSE in the Emergency Department (ED).

These deficient findings did affect two of 23 MR's reviewed including Patient Identifier (PI) # 20, and PI # 23, and had the potential to affect all patients served by the facility ED.

Findings Include:

Refer to A 2406 for findings.

Based on review of medical records (MR), facility Medical Staff Bylaws, facility Medical Staff General Rules and Regulations, facility policy and procedure, and interviews it was determined the facility failed to ensure a Medical Screening Examination (MSE) was performed by a provider who had been approved by the Medical Staff Bylaws as qualified to perform a MSE by the Medical Staff in two of 23 MR's reviewed including PI # 20 and PI # 23.

This deficient practice had the potential to affect all patients presenting to this hospital for emergent care.

Findings include:

1. PI # 20 presented to the ED on 2/10/23 at 8:21 AM with a chief complaint of assault.

Review of the ED Triage assessment dated 2/10/23 at 8:44 AM revealed PI # 20 arrived by private vehicle with complaint of assault with pain to the neck and a laceration to the finger.

Review of the ED MR dated 2/10/23 at 10:20 AM revealed the MSE examination was performed and documented by Employee Identifier (EI) # 6, CRNP (Certified Registered Nurse Practitioner).

Review of the facility Medical Staff Bylaws and Rules and Regulations revealed no documentation the CRNP was approved to perform a MSE.

In an interview conducted on 3/9/23 at 3:32 PM, EI # 3 confirmed EI # 6 was not approved by the Medical Staff Bylaws or General Rules and Regulations to perform a MSE.

2. PI # 23 presented to the ED on 3/2/23 at 6:28 PM with a chief complaint of dizziness.

Review of the ED MR dated 3/2/23 at 6:36 PM revealed the MSE was completed by EI # 7, CRNP and certified as an emergency.

Review of the facility Medical Staff Bylaws and Rules and Regulations revealed no documentation the CRNP was approved to perform a MSE.

In an interview conducted on 3/9/23 at 3:50 PM EI # 1, Chief Executive Officer, confirmed EI # 7 was not approved by the Medical Staff Bylaws or General Rules and Regulations to perform a MSE.