HospitalInspections.org

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Based on interview and document review, the hospital failed to ensure that 1) the qualifications for staff who perform medical screening examinations were specified in the medical staff bylaws, and 2) all emergency department physicians completed annual mandatory Emergency Medical Treatment and Labor Act (EMTALA) education as required by hospital policy.

Failure to ensure that patients receive medical screening examinations by qualified medical staff, and failure to ensure that all providers complete mandatory annual EMTALA education as required by hospital policy places patients at risk for poor health care outcomes, injury, and death.

Findings included:

1. Document review and staff interview showed that the hospital's medical staff bylaws did not identify who was qualified to perform a medical screening examination.

2. The hospital failed to ensure that 16 of 18 emergency department physicians completed their mandatory annual EMTALA education as required by hospital policy

Cross reference: Tag A2406
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ITEM #1 MEDICAL STAFF BYLAWS

Based on interview and document review, the facility failed to ensure that the qualifications for staff who perform medical screening examinations were specified in the medical staff bylaws.

Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional, as specified by the medical staff bylaws, risks poor health care outcomes, injury, and death.

Findings included:

1. On 06/30/21 at 4:30 PM, the investigator and the Clinical Regulatory Compliance and Accreditation Director (Staff #1201) reviewed the hospital's medical staff bylaws. Document review and staff interview showed that the hospital's medical staff bylaws did not identify who was qualified to perform a medical screening examination. Staff #1201 stated that the hospital had inadvertently omitted this section when the new medical staff bylaws were adopted following the hospital's integration into the organization on 01/01/20.


ITEM #2 STAFF EDUCATION

Based on interview and document review, the hospital failed to ensure that 16 of 18 emergency department physicians completed their mandatory Emergency Medical Treatment and Labor Act (EMTALA) annual education as required by hospital policy (Staff #1203, Staff #1204, Staff #1205, Staff #1206, Staff #1207, Staff #1208, Staff #1209, Staff #1210, Staff #1211, Staff #1212, Staff #1213, Staff #1214, Staff #1215, Staff #1216, Staff #1217, Staff #1218, Staff #1219, and Staff #1220).

Failure to ensure that physicians complete mandatory EMTALA annual education and training risks poor patient health care outcomes, injury, and death.

Findings included:

1. On 06/30/21 at 10:30 AM, the investigator interviewed the Director of Emergency Services (Staff #1202). Staff #1202 stated that all patient care staff working in the emergency department (ED), including the physicians, are required to complete annual EMTALA education through the hospital's computer-based learning system.

2. Document review of physician training records showed that 16 of 18 physicians working in the ED 06/01/21 through 06/30/21 did not complete the hospital's required annual EMTALA education between 01/01/20 and 12/31/20.

3. On 07/02/21 at 11:46 AM, the Clinical Regulatory Compliance and Accreditation Director (Staff #1201) confirmed that the physicians were not assigned EMTALA education through the hospital's computer-based learning system, and they did not complete the required EMTALA education during the 2020 calendar year.
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