HospitalInspections.org

Based on review of the hospital and Medical Staff By-laws and Rules and Regulations and staff interviews, the hospital failed to comply with all requirements of 489.24.

Refer to citation at:
A 2406 (489.24(c)) Medical Screening Exam - There was no documentation that the Governing Body had appointed and approved Obstetrical Registered Nurses to conduct medical screening exams. In addition, there was no definition of the qualifications or additional training required for Obstetrical RN staff to be deemed as qualified to perform the medical screening exams; and documentation of staff competencies and training was incomplete for 3 of 5 Obstetrical RN staff records reviewed.

Based on review of the Rules and Regulations of the Medical Staff, hospital's by-laws and staff interviews, the hospital failed to have language in By-laws or Rules and Regulations, approved by the Governing Body, which included obstetrical Registered Nurses (who were conducting medical screening exams at the time of this investigation) as qualified medical personnel to conduct medical screening exams (MSEs); and failed to ensure that nurses performing medical screening exams were trained and deemed to be qualified by documented demonstration of additional required competencies.

Failure to identify training and competency qualifications to conduct medical screening exams risked patient health and safety.

Findings:

Item #1 Failure to identify and approve Obstetrical RNs as qualified to conduct medical screening exams

1. Interview of Emergency Department and obstetrical staff RNs on 4/27-28/2016 showed that obstetrical department RNs performed medical screening exams for pregnant women at greater than 20 weeks gestation that came to the Emergency Department or the Obstetrical Department for medical or obstetrical care

2. Review of the hospital document, "Medical Staff Rules and Regulations" (last revised November 2015) contained language that specified which qualified medical personnel had been approved by the Governing Body to conduct medical screening exams: "Medical screening exams may be conducted by physicians, certified physician assistants or advanced registered nurse practitioners provided they have been given the appropriate clinical privileges." The list did not include Obstetrical Registered Nurses or specify what additional training and competencies were required to qualify to conduct medical screening exams. Per staff interviews on 4/27-28/2016, Obstetrical Registered Nurses were conducting medical screening exams at the time of this investigation.

3. Interview of medical staff administration staff on 4/28/2016, verified that comparable language did not exist in current hospital or medical staff Bylaws or Rules and Regulations.

Item #2 Failure to define a Training and Competency Program to identify requirements for an Obstetrical RN to be qualified to conduct medical screening exams

Based on staff interview, review of policy and procedure and review of human resource documents, the facility failed to ensure that nurses performing medical screening exams were deemed as qualified.

Failure to do so creates risk that emergency services may be rendered to patients from inadequately qualified staff.

Findings:

1. In review of facility policy titled, "EMTALA" [Emergency Medical Treatment and Active Labor Act] (#86100-PCS-102; Revised 11/2014) on page 11 of 13 under the section "Medical Screening Exam" it stated, "An exam performed by a licensed independent practitioner credentialed through the medical staff . . . or a qualified RN working in the Family Birth Center (FBC) to determine, within reasonable clinical confidence, whether an EMC [emergency medical condition] exists."

In review of facility policy titled, "Medical Screening Exam (MSE) of the Obstetric Patient" (# 74010-05-001; Revised 08/2015) on page 2 of 5, item 3 stated, "Upon arrival to the FBC [Family Birth Center] the patient will be provided an Obstetrical MSE by either a FBC practitioner or qualified RN."

2. On 4/28/2016 at 1:30 PM Surveyor #1 interviewed the Regional Director of Women and Children Services (Staff Member #1) about the qualification of Family Birth Center nurses to perform medical screening exams. S/he stated that nursing staff must first complete basic competency to function as a nurse in the FBC. Then the nurse must complete a "Competency Assessment Checklist - Medical Screening Examination" .

In review of the medical screening exam checklist, the signature line completed by the "Employee" and "Evaluator" on the last page of the form stated, "I have read and understand the policy procedure and am subject to disciplinary action . . . if I am not in compliance with the procedures."

When the Director was asked if the signature(s) deemed staff members as qualified to perform medical screening exams, s/he stated that it did not. S/he acknowledged that there was not a facility system to provide specific documentation of staff nurse qualification to perform medical screening exams.

Additionally, the "Registered Nurse Job Description" for Family Birth Center (Revised 12/11) did not address nurse performance of medical screening exams.

3. In review of 3 of 5 staff records, the following documentation omissions were noted related to medical screening exam staff training:

Staff Member # l0 - The "RESIDENCY PLAN & Initial Competency Tool" (Revised 9/2012 and required precedent to medical screening exam training) did not contain the staff nurse's name on the front page and was not signed by the staff nurse on the last page certifying, "Upon completion of successful orientation and demonstrated attainment of general and area-specific competencies, this form to be completed and maintained in employee file."

The nurse began working in the Family Birth Center in January 2013. The nurse subsequently completed medical screening exam training and that form indicated that s/he "Has met basic competencies for LDR [labor delivery recovery] RN" even though that was not identified on the initial competency tool.

Staff Member #11 - A cover page titled, "RN/LPN ORIENTATION SKILL CHECKLIST FAMILY BIRTH CENTER" had blank fields on it including "Employee Name", "Preceptor Name", "Orientation Start Date" and "Unit". The accompanying skills checklist did not contain the employee's name. A competency form titled, "Competency Assessment Checklist - Medical Screening Examination" from January 2010 was not completed.

Specifically, it did not contain the performance ratings for meeting the standard. A subsequent evaluation in May 2015 did not contain a rating for "Has met basic competencies for LDR [Labor Delivery Recovery] RN". Other blank fields included "Date Competence Verified/Evaluator's Initial's" for 5 items, including 23 individual bullet points. The form contained an employee signature but did not provide a date as required with the signature.

Staff Member #12 - A competency form titled, "Competency Assessment Checklist - Medical Screening Examination" form from July 2015 did not contain information for the "Method of Evaluation" for 5 items, including 23 individual bullet points. The form contained an employee signature but did not contain a date as required with the signature.

The above records did not contain sufficient and explicit documentation that the nurses were deemed qualified by the facility to perform medical screening exams.