HospitalInspections.org

Based on review of the hospital Bylaws and/or the Medical Staff Rules and Regulations, the hospital failed to define the appropriate delegation of authority to staff authorized to conduct Medical Screening Examinations in the Labor and Delivery Unit. Based on interview, and review of medical records, and hospital EMTALA policy, the hospital utilizes Labor and Delivery Registered Nurses as Qualified Medical Personnel (QMP) for the purpose of completing Medical Screening Examinations of women who present to the hospital in possible labor. However, based on review of the Hospital Bylaws and Medical Staff Rules and Regulations, the determination of requisite education, clinical skills, and competencies for staff acting in the capacity of QMPs was not delineated in Hospital Bylaws and/or Medical Staff Rules and Regulations approved by the Governing Body. Also, the scope and delegation of authority for these staff acting as QMPs was not delineated as required in the Hospital Bylaws and/or Medical Staff Rules and Regulations approved by the Governing Body.