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A. Based on Hospital Medical Bylaws and Rules and Regulations, record reviews and staff interviews, it was determined that the Hospital failed to ensure compliance with CFR 489.24.

Findings include:

1. The Hospital failed to ensure that Medical Screening Examinations were performed by physicians as required by the hospital in their Medical Bylaws Rules and Regulations.

See deficiency cited at CFR 489.24 (a) (l) (i), A 2406

A. Based on a review of the Hospital Bylaws, Rules and Regulations, review of Hospital policy, record review and staff interviews, it was determined that in 2 of 3 Obstetrical (OB) records reviewed, of a total of 193 OB records from 9/17/10- 10/17/10 (Pt. #19, 21) and 4 of 18 Emergency Department (ED) records reviewed (Pt. #16, 17,18, 20), the Hospital failed to ensure that physicians provided the Medical Screening Examination.

Findings include:

1. A review of the Hospital Bylaws, Rules and Regulations was completed on 10/18/10. Documentation on page 20 of the Rules and Regulations, under "Emergency Services" indicates, 2. "The Emergency Room Physician must establish a procedure to interview, examine and evaluate all patients who present themselves to the Emergency Room." Documentation indicates that the Rules and Regulations were adopted by the Medical Staff on January 9, 2007.

2. A review of the Hospital Policy titled "EMTALA Definitions and General Requirements on page 8, indicates under 5. "The MSE shall be performed by a physician or a QMP as designated by the governing body." Documentation indicated an effective date of October 2009, although no approval by the governing body was given.

3. The medical record of OB Pt. #19 was reviewed on 10/18/10. Pt. #19 presented to the ED on 9/30/10 at 1915 with abdominal pain and was at least 20 weeks gestation. Pt. #19 was sent to the OB floor for assessment and a MSE was completed by a Registered Nurse at 1930. There was no documentation to indicate that Pt. #19 was examined by a physician. Pt. #19 was discharged on 9/30/10 at 2037.

4. The medical record of OB Pt. #21 was reviewed on 10/18/10. Pt. #21 presented to the ED on 10/6/10 at 1430 with diagnosis of "labor determination." Pt. #21 was at least 20 weeks gestation and was sent to the OB floor for assessment. Documentation indicates a MSE was completed by a Registered Nurse. There was no documentation to indicate that Pt. #21 was examined by a physician. Pt. #21 was discharged on 10/6/10 at 1535.

5. The medical record of Pt. #16 was reviewed on 10/18/10. Pt. #16 presented to the ED on 10/10/10 at 0831 with complaint of eye problems. Documentation indicated Pt. #16 was triaged at 0834 and an MSE was completed by a Nurse Practitioner (NP) at 0906. There is no documentation to indicate that Pt. #16 was examined by a physician. Pt. #16 was discharged on 10/10/10 at 0942.

6. The medical record of Pt. #17 was reviewed on 10/18/10. Pt. #17 presented to the ED on 10/02/10 at 0902 with complaints of head and chest congestion. Documentation indicated Pt. #17 was triaged at 0903 and an MSE was completed by a NP at 0928. There is no documentation to indicate that Pt.# 17 was examined by a physician. Pt. #17 was discharged on 10/02/10 at 1046.

7. The medical record of Pt. #18 was reviewed on 10/18/10. Pt. #18 presented to the ED on 10/01/10 at 2304 with complaints of abdominal pain and was 17 weeks gestation. Documentation indicated Pt. #18 was triaged at 2309 and an MSE was completed by a Physician Assistant (PA) at 0132. There is no documentation to indicate that Pt. #18 was examined by a physician. Pt. #18 was discharged on 10/02/10 at 0254.

8. The medical record of Pt. #20 was reviewed on 10/18/10. Pt. #20 presented to the ED on 10/08/10 at 1920 with complaints of fever and vomiting. Documentation indicated Pt.
#20 was triaged at 1522 and an MSE was completed by a NP at 1909. There is no documentation to indicate that Pt. #20 was examined by a physician. Pt. #20 was discharged on 10/08/10 at 1931.

9. During an interview with the Assistant Nurse Manager of OB on 10/18/10 at 3:00 PM it was reported that Registered Nurses (RN) who have been approved through competency to provide MSE's have been providing some of the MSE's to OB patients who are at least 20 weeks gestation and are sent to the OB floor for assessment. During the interview, the Assistant Nurse Manager reported that the policy regarding this practice has not been approved by the governing body as of 10/18/10.

10. During an interview with the Director of Emergency Medical Services on 10/18/10 at 3:30 PM, it was reported that the EMTALA policy allowing a physician or a QMP to provide the MSE was effective October 2009 but as of 10/18/10 was not approved by the governing body. In the interview, the above findings were confirmed.