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HILL HOSPITAL OF SUMTER COUNTY
COMPLIANCE WITH 489.24
Tag No.: A2400
Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, facility registration log, Emergency Department (ED) log, Medical Records (MR), Ambulance Run Report and staff interviews, it was determined Hill Hospital of Sumter County (Hospital A) failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the ED in the facility bylaws or rules and regulations.
Findings include:
Refer to A2406 for findings.
MEDICAL SCREENING EXAM
Tag No.: A2406
Based on review of the Medical Staff Bylaws and Rules and Regulations and interviews with staff it was determined the facility failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.
This deficient practice had the potential to affect all patients served by the facility ED.
Findings include:
The facility bylaws and rules and regulations were received from Employee Identifier (EI) # 1, Director of Nursing, on 9/22/2020.
Review of the facility bylaws and rules and regulations on 9/22/2020 revealed no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED.
An interview was conducted with EI # 1 on 9/22/2020 at 3:00 PM who confirmed there was no documentation to identify and approve the individual(s) qualified to perform the MSE in the facility Medical Staff Bylaws and Rules and Regulations.
A second interview was conducted via phone on 9/24/2020 at 8:50 AM with EI # 2, Administrator, who verbalized there was no documentation to identify and approve the individual(s) qualified to perform the MSE in the facility Medical Staff Bylaws and Rules and Regulations. EI # 2 further verbalized when the Medical Staff Bylaws and Rules and Regulations were redone (retyped in 2019 per the documentation) the part to identify and approve the individual(s) qualified to perform the MSE was left out. On 9/24/2020 at 10:00 AM, the surveyor received via email an addendum to the facility bylaws and rules and regulations dated 9/24/2020 at 8:00 AM, approved by the governing body and medical staff, to include the individual(s) qualified to perform the MSE at the facility.