HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to include in their Medical Bylaws the responsible person to provide a medical screening examination. Refer to A-2406.

Based on document review and interview, it was determined that the Hospital failed to ensure the Medical Staff Bylaws and/or Rules and Regulation indicated the individual(s) deemed qualified to conduct Medical Screening Examinations (MSE) in the Emergency Department (ED). This has the potential to affect an average of 82 patients undergoing MSEs in the emergency room each day.

Findings include:

1. On 8/14/17 at approximately 11:00 AM, the Medial Staff Bylaws and Rules and Regulations, approved by the Board of Trustees on 6/26/17, were reviewed. The Medical Staff Bylaws and Rules and Regulations failed to include the qualified medical prctitioner(s) appointed/approved to conduct MSEs.

2. On 8/14/17 at 2:05 PM, an interview was conducted with the Vice President of Quality/ Corporate Compliance Officer (E #7). E #7 stated, "The Emergency Room MSE qualifications are not in the bylaws."