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Based on review of facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, and staff interview, it was determined that the facility failed to ensure compliance with 42 CFR 482.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Findings were:

Cross refer to A2406 as it relates to the facility's failure to identify in the Medical Staff Bylaws/Rules and Regulations those individuals qualified to perform medical screening examinations.

Based on review of Medical Staff Bylaws/Rules and Regulations, policy and procedure, and staff interview, it was determined that the facility failed to identify in the Medical Staff Bylaws/Rules and Regulations those individuals who were determined qualified to perform medical screening examinations.

Findings were:


The Medical Staff Bylaws/Rules and Regulations indicated that an appropriate Medical Screening Examination (MSE) as required by the Emergency Medical Treatment and Active Labor Act would be provided in accordance with Hospital policy LL.EM.001 and Palmyra Medical Screening protocol. A review of policy #LL.EM.001 entitled "EMTALA - Definitions and General Requirements", effective May 2010, identified persons who were qualified to perform medical screening exams. Qualified medical personnel was defined as an individual, in addition to a licensed physician, who is licensed or certified and who has demonstrated current competence in the performance of MSEs. This policy referenced the following examples of professionals that may be approved by a hospital's governing board: registered nurse in perinatal services (depending on state law), psychiatric social worker (depending on state law), registered nurse in psychiatric services (depending on state law), psychologist, physician assistant, advanced registered nurse practitioner, and certified registered nurse midwife. The policy indicated that these examples of professionals may be approved by a hospital's governing board as qualified to administer one or more types of initial MSEs and complete/sign a certification for transfer in consultation with a physician when a physician was not physically present in the dedicated emergency department. The policy further indicated that each hospital's governing board must make such a determination on behalf of the hospital through the hospital's by-laws or rules and regulations.

An interview was conducted on 04/11/12 at 2:00 p.m. with the Director of Medical Staff Services in the administrative conference room. The interviewee confirmed that the Medical Staff Bylaws/Rules and Regulations lacked documented evidence of qualified individuals approved by the hospital's governing board to perform medical screening examinations.