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Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review and interviews with staff it was determined the facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.


Finding Include:

Refer to A 2406 for findings.

Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review and interviews with staff it was determined the facility failed to identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations.

This deficient practice affected three (3) of twenty one MR's reviewed, including Patient Identifier (PI) # 11, PI # 12, and PI # 17 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: Emergency Medical Treatment and Labor Act (EMTALA)
Policy Number: 2.01.72
Effective Date: 3/4/21

Purpose: This policy is to ensure compliance with the EMTALA requirements for any individual seeking emergency services... In keeping with the Core Values of Providence Hospital, this policy serves as an outline of the hospital's processes to ensure compliance with the requirements of the EMTALA.

Policy:

A. It is the policy of Providence Hospital that any individual who comes to the Hospital...who is in need of or requests emergency medical services will be provided necessary emergency medical services as described below...

1. MSE by a physician or Qualified Medical Person (QMP) to determine if the individual has an Emergency Medical Condition (EMC)...

Procedure:

A. MSE

1. The hospital shall provide a MSE for every individual who comes to the ED seeking medical treatment...

Definitions:

...QMP means an individual who is licensed or certified by the Hospital's Medical Staff and Board of Director's in the following professional categories and who has demonstrated current competence in the performance of the MSE; a QMP which includes registered nurses qualified in triage in the ED and/or L&D (Labor and Delivery), a physician, a physician's assistant (PA), or nurse practitioner (CRNP) under the direction of a physician.

The above-referenced categories of professionals have been approved by the Hospital's governing body as qualified to administer one or more types of MSE....

1. The facility Medical Staff Bylaws and Rules and Regulations were received from Employee Identifier (EI) # 1, Vice President of Patient Care, on 9/6/22.

Review of the facility bylaws and rules and regulations on 9/8/22 revealed documentation of "...F. Emergency Medicine. The emergency Physician is required to evaluate the complaints and condition of any patient presenting in the ED, to provide initial stabilization, and to determine the disposition of each patient..." There was no documentation the facility designated a Physician Assistant (PA) and/or a Certified Registered Nurse Practitioner (CRNP) as qualified in the facility bylaws or rules and regulations to perform the MSE.

PI # 11 presented to the facility ED on 3/8/22 at 2:44 PM with chief complaint of chest pain radiating down to abdomen and around right side to lower back.

Review of the MR documentation revealed the MSE was conducted on 3/8/22 at 3:04 PM by a PA and not an ED physician.

PI # 12 presented to the facility ED on 3/17/22 at 5:30 PM with chief complaint of head injury and assault by manual strangulation.

Review of the MR documentation revealed the MSE was conducted on 3/17/22 at 10:26 PM by a PA and not an ED physician.

PI # 17 presented to the facility ED on 5/20/22 at 5:14 PM with chief complaint of syncope.

Review of the MR documentation revealed the MSE was conducted on 5/20/22 at 5:18 PM by a CRNP and not an ED physician.

An interview was conducted with EI # 2, Administrator, on 9/9/22 at 3:18 PM who confirmed there was no documentation in the facility bylaws or rules and regulations a PA and CRNP were designated as qualified to perform the MSE in the ED prior to 9/8/22.