Washington Regional Medical Center

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 41508 Based on review of the obstetric (OB) and emergency department (ED) employee education files, obstetric registered Nurse (RN) job description, Medical Staff by-laws rules and regulations, and interviews, the hospital 1. Failed to ensure that six of six OB RNs (RN 1, 2, 3, 4, 5, and 6) in a total universe of 44 Labor, Delivery, Recovery, Postpartum (LDRP) RNs had a job description that include the additional job skills of ED triage and Qualified Medical Professional (QMP), 2. Failed to ensure that the medical staff included LDRP RNs as QMPs in their by-laws rules and regulations, had obtained the governing body (GB) review and approval for LDRP RNs as QMPs and/or defined the qualification, training and competency for the LDRP RN’s for 44 of 44 LDRP RNs (RN1, 2, 3, 4, 5, 6, and RNs 19 - 56). The failed practice did not ensure the LDRP RNs were qualified to conduct MSE. See A-0048 for details.”

“MEDICAL STAFF - BYLAWS AND RULES CFR(s): 482.12(a)(4) [The governing body must] approve medical staff bylaws and other medical staff rules and regulations. This Standard is not met as evidenced by: 41508 Based on review of the obstetric (OB) and emergency department (ED) employee education files, obstetric registered Nurse (RN) job description, Medical Staff by-laws rules and regulations, and interviews, the hospital 1. Failed to ensure that six of six OB RNs (RN 1, 2, 3, 4, 5, and 6) in a total universe of 44 Labor, Delivery, Recovery, Postpartum (LDRP) RNs had a job description that include the additional job skills of ED triage and Qualified Medical Professional (QMP), 2. Failed to ensure that the medical staff included LDRP RNs as QMPs in their by-laws rules and regulations, had obtained the governing body (GB) review and approval for LDRP RNs as QMPs and/or defined the qualification, training and competency for the LDRP RN’s for 44 of 44 LDRP RNs (RN1, 2, 3, 4, 5, 6, and RNs 19 - 56). The failed practice did not ensure the LDRP RNs were qualified to conduct MSE. Findings include: A. Review of the Medical Staff by-laws rules and regulation approved by the GB on 12/19/23 defined the “Clinical Specialist” as “The Clinical Specialist category shall include those AHPs (Allied Health Professionals) who are employed by a Member and who have been authorized by Washington Regional to provide care, treatment, and services only under the supervision of their Sponsoring Member. ...6. Registered Nurse (RN) ARTICLE IV . . . I. Emergency Care The responsibility for providing emergency care within Washington Regional rests with the Medical Staff. Because this responsibility cannot be delegated, every active and provisional active Member shall serve according to the published call schedule and be available for emergency room and for inpatient emergencies. ... Any individual who comes to the Emergency Department and requests treatment or examination for a medical condition or has such a request made on their behalf, shall receive an appropriate medical screening examination performed by a “Qualified Medical Person.” The term “Qualified Medical Person” shall be defined as physicians, advanced registered nurse practitioners, physician assistants, Sexual Abuse Nurse Examiners, and obstetric registered nurses. ... Where a pregnant woman presents to the Emergency Department and requests examination, or treatment of symptoms related to labor or has such a request made on their behalf| an Obstetric Registered Nurse or physician shall perform the medical screening examination.” The medical staff rules and regulations did not include a list of LDRP RNs that have been approved by the Governing Board and did not include the EMTALA law requirements, defined training, qualifications, or competencies to ensure that the LDRP RNs remained competent in the specialty skills required to conduct emergency Medical Screening Exams as a QMP. B. Review of the hospital’s job description for the RNs working in LDRP titled “Registered Nurse - Women and Infants,” dated 07/22, showed that under the header “Position Summary” the definition for the specialty role of the QMP was not included. Review under the header “Essential Position Responsibilities,” did not include the responsibilities of the specialty role of the QMP. Under the header “Qualifications,” the QMP qualifications were not included. C. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID #1) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 02/21/14. There was no evidence provided of other training, qualifications, or competencies for this QMP. D. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID #2) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 05/19/18. There was no evidence provided of other training, qualifications, or competencies for this QMP. E. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID #3) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 06/06/24. There was no evidence provided of other training, qualifications, or competencies for this QMP. F. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID #4) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 12/27/23. There was no evidence provided of other training, qualifications, or competencies for this QMP. G. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID # 5) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 12/23/21. There was no evidence provided of other training, qualifications, or competencies for this QMP. H. Review of the employee training, qualifications, and competency file for LDRP RN (Staff ID #6) showed the “Triage of the OB Patient and Medical Screening Exam (MSE) Competency and Evaluation” was completed as an initial competency on 10/20/21. There was no evidence provided of other training, qualifications, or competencies for this QMP. I. During an interview on 09/25/24 at 2:34 PM, the Woman and Infant Director (Staff ID #7) and the RN Educator (Staff ID #8) stated that although not defined in the Medical staff by-laws, rules, and regulations, the LDRP RNs must have at minimum one year of LDRP experience to train and test to become a QMP. The Woman and Infant Director 7 and RN Educator 8 confirmed that the LDRP RN job description did not include the additional skills, training, or competencies for the EMTALA [Emergency Medical Treatment and Labor ACT] QMP designation. Woman and Infant Director (Staff ID #7) and the RN Educator (Staff ID # 8) confirmed that the competency form allows for “initial,” “annual,” or “other” and aside from the “initial” the LDRP RNs did not have annual training, qualifications, or competencies to perform an EMTALA MSE. J. During an interview on 09/26/24 at 9:02 AM, the Director of Medical Staff and Continuing Medical Education (Staff ID #57) stated that the Medical Executive Committee had oversight of the Advanced Practice Registered Nurse and Medical Staff defined as QMPs for training, qualifications, and competencies, but the LDRP RNs were not privileged or approved by the Medical Executive Committee or the Governing Body as QMPs, stating that oversight was the responsibility of HR(Human Resources) and LDRP. K. During an interview on 09/26/24 at 10:38 AM while reviewing the Medical staff by-laws rules and regulations related to the QMP qualifications, Vice President of Human Resources (VPHR) (Staff ID #18) and Chief Nursing Officer (CNO) (Staff ID #17) confirmed that even though the LDRP RN’s were listed in the Medical staff by-laws rules and regulations as being QMPs, the Medical Staff services had no oversight of the LDRP RNs, that the LDRP Director and HR had that oversight, and there were no defined training, qualifications or competencies for the specialized role of the QMP.. L. On 09/26/24 at 11:20 AM, the Woman and Infant Director (Staff ID #7) provided a full list of all LDRP RNs currently working in LDRP. A total of 44 RNs were documented as having been designated as a QMP. Woman and Infant Director (Staff ID #7) confirmed that the remaining 38 LDRP RNs LDRP RN (Staff ID #19 through 56) did not have defined qualifications, training, or competencies beyond the “initial” competency. M. During an interview on 09/26/24 at 11:06 AM, the Chief of Staff (Staff ID #15) confirmed that the Medical staff by-laws, rules, and regulations defined the LDRP RNs as QMPs to conduct EMTALA MSEs for patients coming to the LDRP department seeking care for a potential medical emergency. When asked how the Medical Executive Committee determined which LDRP RNs were qualified to conduct EMTALA MSEs, the Chief of Staff (Staff ID #15) stated the RNs were usually paired with an OB Hospitalist and checked off by the Hospitalist as qualified, usually after a year of OB experience. The Chief of Staff (Staff ID #15) confirmed that the Medical Staff Executive Committee had not defined the qualification training and competencies for consistency among the QMPs. When asked who set the qualification training and competencies for the Physician and APRN QMPs, the Chief of Staff (Staff ID #15) confirmed that it was the Medical Executive Committee. The Chief of Staff (Staff ID #15) stated he/she was not aware of a Governing Body approved list of LDRP RNs based on qualifications, training, and competencies.”