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TOUCHETTE REGIONAL HOSPITAL INC 5900 BOND AVENUE CENTREVILLE, IL 62207 Nov. 16, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, it was determined for 6 of 21 patients ( #5, #6, #7, #15, #16, #17) being medically screened for the presence of an emergency medical condition the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure the Medical Screening Exam (MSE) was performed by a qualified practitioner as designated by the Medical Staff Bylaws, Rules and Regulations. (A2406)
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on interview and document review, it was determined for 3 of 4 (Pts #15, #16, and #17) patients who presented to the Obstetrics (OB) Department and 3 of 17 (Pts #5, #6, and #7) patients who presented to the Emergency Department (ED) requesting a Medical Screening Exam (MSE), the Hospital failed to ensure the MSE was performed by a qualified practitioner as designated by the Medical Staff Bylaws, Rules and Regulations. This has the potential to affect all patients serviced by the Hospital which services an average of 62 OB patients per month and an average of 1,581 ED patients per month.

Findings include:

1. An interview was conducted with the Director of the Emergency Department (E#1) on 11/12/15 at approximately 10:50 AM. When asked who is designated by the Medical Staff to perform the MSE in the ED and in the OB Department, E#1 stated the MSE is performed by the ED physician and/or Midlevel providers (Physician Assistant-PA and Advanced Practice Nurse- APN) in the ED and a physician or the OB nurses RNs) perform the MSE for pregnant women who present to the ED "either over 16 or 20 weeks who come in with a pregnancy related concern like contractions or abdominal pain. If it's an accident (motor vehicle accident) or something unrelated to the pregnancy, they are seen in the ED to be sure nothing else is wrong and then they might or might not go up to OB to be checked. Sometimes the nurses (OB) come down to the ED to check them (the patients)."

2. An interview was conducted with the Director of OB (E#7) on 11/12/15 at approximately 2:10 PM. E#7 stated the nursing staff (Registered Nurses) perform the MSE and then call the physician with a report and obtain further orders at that time.

3. Pt #15's record was reviewed on 11/12/15. Pt #15 (MDS) dated [DATE] at approximately 10:30 PM with the Chief Complaint (CC) Abdominal Pain and Bleeding. On 10/11/15 at approximately 10:49 PM, OB documentation stated the OB RN (E#14) performed the MSE.

4 Pt #16's record was reviewed on 11/12/15. Pt #16 (MDS) dated [DATE] at approximately 11:15 PM with the CC Contraction and questionable Premature Rupture of Membranes. On 11/4/15 at approximately 11:15 PM, OB documentation stated the OB RN (E#12) performed the MSE.

5 Pt #17's record was reviewed on 11/12/15. Pt #17 (MDS) dated [DATE] at approximately 8:40 AM with the CC Rule Out Labor. On 10/11/15 at approximately 8:40 AM, OB documentation stated the OB RN (E#16) performed the MSE.

6. Pt #5's record was reviewed on 11/13/15. Pt #5 (MDS) dated [DATE] at approximately 12:23 PM with the Chief Complaint (CC) Abdominal Pain. On 11/7/15 at approximately 12:30 PM, ED documentation stated APN #1 performed the MSE.

7. Pt #6's record was reviewed on 11/13/15. Pt #6 (MDS) dated [DATE] at approximately 3:38 PM with the CC Abdominal Pain. On 11/4/15 at approximately 3:40 PM, ED documentation stated PA-C #2 performed the MSE.

8. Pt #7's record was reviewed on 11/13/15. Pt #7 (MDS) dated [DATE] at approximately 11:36 AM with the CC Blood in Stool Melena. On 11/10/15 at approximately 2:00 AM, ED documentation stated PA-C #2 performed the MSE.

9. The Medical Staff Bylaws (revised May 2013) and Rules and Regulations (revised 10/14/09) were reviewed on 11/12/15 at approximately 2:00 PM. Under 8.1A.4: B. E.M.S. (Emergency Medical Services) Physician Responsibilities, the Rules and Regulations stated "1. E.M.S. physicians shall at all times perform the independent practice of medicine. Patients who come to the E.M.S. shall receive a screening by physicians with Emergency Medicine clinical privileges and specialty on-call physicians as needed in the judgment of the on-site physician ... 8.1A.5: The Evaluation and Care of Patients in the E.M.S.: A. The E.M.S. physician shall examine and treat all persons who present themselves to the E.M.S. requesting evaluation and treatment, irrespective of the patient's race, color, religion or ability to pay." The Bylaws, Rules and Regulations lacked any designation of the ability of the MSE to be performed by a Midlevel provider in the ED or the Registered Nurse (RN) in OB with approved training in the performance of a MSE as determined by the Medical Staff.

10. The Hospital policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Guideline for Emergency Services Patients" (revised 11/13) was reviewed on 11/12/15. The policy stated all patients would receive a MSE but did not designate who would conduct the MSE either in the ED or in OB.

11. An interview was conducted with E#1 and E#7 on 11/12/15 at approximately 3:00 PM. Both stated they were unaware the Medical Staff Bylaws, Rules and Regulations lacked the approval for the Midlevels to perform the MSE in the ED and the OB RNs (trained in the MSE) to perform the MSE in OB. Both further stated they thought the EMTALA policy also designated who could perform the MSE in the ED and in OB.

12. An interview was conducted with the Chief Operating Officer (E#2) on 11/13/15 at approximately 8:30 AM. E#2 had reviewed both the Medical Staff Bylaws, Rules and Regulations and the EMTALA policy and stated "We are in the process of updating our Bylaws (and Rules and Regulations) to make sure they have everything we need." E#2 verbally agreed the EMTALA policy did not state who could do the MSE in the ED or in OB.