HospitalInspections.org

Based on document review and interview, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to ensure an adequate medical screening exam was performed by a qualified medical professional as appointed in the Bylaws, See A 2406.

Based on document review and interview the facility failed to ensure that the medical screening exam (MSE) was performed by a qualified medical professional (QMP) as determined by the hospital bylaws and was complete resulting in the potential for poor patient outcomes for all patients served. Findings include:

On 3/25/16 at approximately 1530 during review of the facility hospital bylaws it was determined that the QMP was not designated in the bylaws.

On 3/25/16 at approximately 1545 during an interview with staff M the surveyor asked if the bylaws, policy or other document contained guidance on who was considered a QMP to perform a MSE. Staff M stated "It's not in a policy or our bylaws, we use the credentialing process and determine individually who is qualified."

QIO review determined for patient #1 "84 y/o (year old) F (female) brought to ED (emergency department) for evaluation progression confusion. Pt. (patient) had incomplete MSE by QMP. Although UA (urinalysis)/CBC (complete blood count)/CMP (complete metabolic panel) were done, no CT head (diagnostic test similar to x-ray) or TSH (thyroid stimulating hormone) were ordered. Further, HTN (hypertension (high blood pressure)) was not addressed and pt discharged (d/c'd) w/ (with) BP (blood pressure) 164/112. Pt was not stabilized at discharge as MSE was incomplete.

QIO review determined for patient #2 7 mo (month) old F (female) infant brought to ED for cough. Pt had incomplete MSE by QMP. Pt w/ temp 99.3 and HR (heart rate) 174. No CXR (chest x-ray)/CBC/urinalysis (UA) done. No repeat vitals done. Pt given steroids and antibiotics (ABX) and discharged.