HospitalInspections.org

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ITEM #1: Post Signs

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to post signs notifying patients waiting in emergency department treatment areas that they had a right to a medical screening examination (MSE) and stabilizing treatment; and whether or not the hospital participated in the Medicaid program.

Failure to post this information risked violation of the patient's right to receive a medical screening examination, stabilizing treatment, and/or transfer regardless of ability to pay for services.

Cross Reference: Tag C2402


ITEM #2: Medical Staff Bylaws

Based on interview and document review, the hospital failed to ensure that the medical staff bylaws determined which individuals were qualified to provide medical screening examinations (MSEs).

Failure to determine which individuals are qualified to provide medical screening examinations places patients at risk for substandard care by receiving MSEs from unqualified personnel.

Cross Reference: Tag C2406

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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to post signs notifying patients waiting in emergency department treatment areas that they had a right to a medical screening examination (MSE) and stabilizing treatment; and whether or not the hospital participated in the Medicaid program.

Failure to post this information risked violation of the patient's right to receive a medical screening examination, stabilizing treatment, and/or transfer regardless of ability to pay for services.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Procedure," policy number 9306589, showed the following:

a. Signs notifying patients of their right to a medical screening exam (MSE) must be posted in places likely to be noticed by patients entering the emergency department (ED) or Labor and Delivery, as well as individuals waiting for examination and treatment in other areas of the medical center, including, but not limited to, entrances, admitting areas, waiting rooms, and treatment rooms.

b. Signs in lobbies or waiting areas must be posted in such a way that they are conspicuous and visible to patients in those areas.

c. Signs posted in registration, triage, or examination rooms may be smaller than those in the waiting rooms but must be clearly readable from the patient's position.

2. On 04/20/22 at 10:52 AM, during a tour of the emergency department (ED) with the Director of Nursing (Staff #1204) and the ED Manager (Staff #1205), the investigator observed the following:

a. Two signs posted notifying patients of their right to a MSE and stabilizing treatment regardless of ability to pay and that the hospital participated in the Washington State Medicaid program, including an 8 ½ by 11 inch paper sheet posted on the wall next to the exit doors, and a larger white placard with red letters posted on a wall near the Check-In Station #1.

b. The investigator observed there were no signs posted in the ED entrance, the vending area, in 0 of 2 waiting rooms, or at Check-In Station #2.

3. At the time of the observation, Staff #1204 and Staff #1205 confirmed there was no further signage in the ED entrance, check-in, or patient waiting areas.
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Based on interview and document review, the hospital failed to ensure that the medical staff bylaws determined which individuals were qualified to provide medical screening examinations (MSEs).

Failure to determine which individuals are qualified to provide medical screening examinations places patients at risk for substandard care by receiving MSEs from unqualified personnel.

Findings included:

1. Record review of the hospital's Medical Staff Bylaws, approved by the medical staff 07/18, and the governing board 08/18, showed that they did not identify the qualifications of individuals approved to perform medical screening exams in the emergency department (ED).

2. Record review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance Procedure," policy number 9306589, last reviewed 03/20, showed that the hospital will provide an appropriate MSE from physicians or qualified medical persons (QMPs), as defined by the governing board.

3. On 04/21/22 at 2:00 PM, the investigator interviewed the Medical Staff Director (Staff #1206). Staff #1206 confirmed the investigator's finding that the medical staff bylaws did not identify which individuals were qualified to perform medical screening exams in the ED.
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