The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MERCYHEALTH HOSPITAL ROCKTON AVENUE 2400 NORTH ROCKTON AVENUE ROCKFORD, IL 61103 March 21, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure the Bylaws and/or Rules and Regulations included who was determined to be qualified to complete a medical screening exam. See deficiency A-2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on document review and interview, it was determined that the Hospital failed to ensure that the Medical Staff Bylaws and Rules and Regulations included the individual(s) deemed qualified to conduct Medical Screening Examinations (MSE) in the Emergency Department (ED). This has the potential to affect an average of 130 patients presenting to the Hospital's ED each day.

Findings include:

1. On 3/19/18 at approximately 2:00 PM, the Hospital's Medical Staff Bylaws and Rules and Regulations (approved 9/22/15) were reviewed and lacked determination of which members of the Medical Staff were qualified to perform and/or delegate the performance of a medical screening exam (MSE).

2. On 3/20/18 at approximately 11:30 AM, the Hospital's policy entitled, "Medical Screening Exam Qualified Examiner" (approved 12/8/15) was reviewed and included, "...The examination must be performed by an individual(s) who is determined qualified by the policies, Bylaws and/or Rules and Regulations..."

3. On 3/20/18 at approximately 11:45 AM, the Hospital's policy entitled, "Delegation of Medical Screening Exam" (approved 6/9/2014) was reviewed and included, "...Emergency Department: The Emergency Department Nurse Practitioner and Physician Assistant are delegated the authority by the Hospital Medical Staff to perform Medical Screening Exams and to provide stabilizing treatment...Obstetrics: The obstetrical registered nursing staff, who have been qualified by virtue of their annual competency and unit requirements as determined on an individual basis by the Chair of the Department of Obstetrics, are delegated by the Hospital Medical Staff the authority to perform Medical Screening Exams..."

4. On 3/19/18 at approximately 2:00 PM, an interview was conducted with the emergency room Medical Director (MD #4). MD #4 stated that Medical Screening Exams in the ED are performed by emergency room Physicians, and the ED does not utilize mid level practitioners. Therefore, every patient seen in the emergency room receives a Medical Screening Exam by an emergency room Physician.

5. On 3/20/18 at approximately 1:30 PM, an interview was conducted with the Vice President of Quality ( E#3). E #3 stated that the Medical Bylaws do not specify who can perform Medical Screening Exam, but the policies do address who can perform the Medical Screening Exam.