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EVERGREENHEALTH MEDICAL CENTER 12040 NE 128TH STREET KIRKLAND, WA 98034 June 21, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on staff interview and review of hospital policies and procedures, the hospital failed to comply with all requirements of 489.24

Refer to example at:

A 2406 (489.24(a)) Medical Screening Exam - Failed to have language in hospital regulations or by-laws, approved by the Governing Body, that specified which medically qualified personnel had been approved to conduct emergency medical screening exams (MSEs).
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of the hospital's regulations, by-laws and staff interviews, the hospital failed to have language in by-laws or regulations approved by the Governing Body, that specified which qualified medical personnel (QMPs) had been approved to conduct medical screening exams (MSEs).

Findings:

Interview with administrative staff on 6/19/18, showed that ED physicians performed medical screening exams for ED patients, and obstetrical department RNs with specific training and competencies performed medical screening exams for patients who came to the obstetrical department. The procedures were written in hospital policies and procedures, but were not in hospital rules, regulations, or bylaws.

Staff interview on 6/20/18 verified that OB RNs were trained and competent to perform the MSEs for pregnant women as directed in hospital procedures.

Staff review of hospital's by-laws failed to evidence that the Governing Body had identified and approved which qualified medical personnel were to conduct Medical Screening Exams in current hospital or medical staff regulations and bylaws. Upon determination of this finding, Administrative staff acted immediately to correct the oversight.