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Based on interviews and facility document review, it was determined the facility staff failed to comply with §489.24 - Special Responsibilities of Medicare Hospitals in Emergency Cases.

The findings include:

The facility staff failed to ensure the facility's written bylaws and/or rules and regulations addressed which individuals were deemed qualified to complete the medical screening exams for patients presenting to the facility for emergency medical treatment.

Please see Tag A2406 for additional information.

Based on interviews and facility document review, it was determined the facility staff failed to ensure written bylaws and/or rules and regulations addressed which individuals were deemed qualified to complete the medical screening exam to determine if a patient presenting to the facility for emergency treatment had an emergency medical condition.

The findings include:

The survey team initiated an entrance conference on the afternoon of 11/27/17 at approximately 3:30 p.m. Facility members in attendance included the Director of Credentialing (DofC), Chief Quality Officer (CQO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO). The survey team requested the facility's bylaws and/or rules and regulations that identify which individuals were permitted to complete medical screening exams for patients seeking emergency care.

On 11/28/17 at 8:40 a.m., the DofC reported to the survey team that the facility only has one set of bylaws and no separate document containing rules and regulations. The DofC stated the bylaws did not address who has been determined able to do the medical screening exam; the DofC stated the facility's policy and procedures identify who is able to complete the medical screening exam. The bylaws provided to the survey team were entitled, "Amended and Restated Bylaws of the Clinical Staff of the University of Virginia Medical Center".

On 11/28/17 at 3:35 p.m., a survey team meeting was conducted with the facility's Chief Medical Officer (CMO), the Medical Director of the Emergency Department, the Medical Director of Obstetrics, and the DofC. The facility's bylaws not identifying who is deemed able to complete medical screening exams was discussed. The facility's policies and procedures addressing medical screening exams were reviewed. The obstetric policies and procedures detailed who was required to assess the patient prior to the patient being discharged but did not use the wording of medical screening exam and/or emergency medical condition. The policies guiding the emergency department did detail the individuals who were required to examine the patient.

The following information was found in a facility policy entitled, "Medical Center Policy No. 0214": " ...the Medical Center shall provide an appropriate medical screening examination to determine whether an emergency medical condition exists ..."

The following information was found in a facility policy entitled, "Emergency Department Procedure No. S-6":
- "Upon arrival in the Emergency Department, a Health Care Professional trained in ED Screening and Triage, shall begin MSE [sic] on all presenting patients to determine if an emergency medical condition exists" and
- "All patients will begin the screening exam with an oriented Screening RN, (or other appropriately trained licensed medical personnel (i.e. RN, NP, PA, MD.) [sic]" (RN = registered nurse; NP = nurse practitioner; PA = physician assistant; MD = doctor of medicine)

The following information was found in a facility policy entitled, "Emergency Department Procedures No.: T-5": "Each patient who presents for treatment of an emergency condition will have a medical screening examination performed by a physician and/or nurse practitioner or physician assistant."