Based on interviews and review of hospital documents, including Medical Staff bylaws and physician contracts, it was determined that the hospital failed to ensure that the emergency services organization and direction requirements were met. The hospital's failure to do so resulted in a lack of provider and staff qualifications being determined by the medical staff, lack of complete position descriptions, lack of an organizational chart and lack of a complete and accurate Scope of Services for the Emergency Department. Findings include: MEDICAL STAFF BYLAWS On May 24, 2016, at 1:30 PM, the Director of Medical Staff Services was interviewed and asked to provide documentation that the medical staff had defined the qualifications of medical staff and other providers in the ED and was unable to do so. It was determined that the hospital failed to ensure that the emergency services organization and direction requirements are met. The Director was asked to provide a copy of the job description for the ED Medical Director. The Director provided pages 4 & 5 of the contract between the contracting physician's group and the hospital, which outlined job duties. The document did not specify the name of the hospital, did not specify what board-certification the medical director must have, or if board certification was required, and did not specify the amount, or type, of experience the medical director must have. The document did not have a date the job description was effective, or for how long the job description was effective, when the document would be reviewed, or a signature. The document did not specify the name of the hospital; did not specify criteria for qualifications for the medical director. The document did not have a date the job description was effective, when the document would be reviewed, or a signature of the physician or a hospital representative. The Medical Director was interviewed on May 24, 2016 and stated that s/he had board certification in Family Medicine (verified by review of the physician's credentialing file). The Medical Director stated that the hospital accepted physicians who were board-certified in either Family Medicine or Emergency Medicine, and there was one ED physician who was board-certified in Internal Medicine and had been "grandfathered" in. A second ED physician, who stated that s/he had formerly been the ED Medical Director, stated that s/he was board-certified in Family Medicine (verified by review of the physician's credentialing file). POSITION DESCRIPTIONS ED Medical Director - See above under "Medical Staff Bylaws" The hospital's policy and procedure "Triage for Emergency Department" stated "An experienced RN who is trained in triage, and is ACLS certified, will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity..." Triage Nurse/Staff Nurse - The Director of Clinical Services for the ED stated on May 19, 2016 that there was no job description specific to triage nurses. The Director stated that ED staff nurses were assigned to triage duties in the absence of a dedicated triage nurse; however, the ED staff nurse job description did not include triage duties.

Based on interview and review of hospital documents, it was determined that the hospital failed to assure that the Emergency Department (ED) services were organized under the direction of a qualified member of the medical staff. The hospital's failure to do so resulted in the Governing Body not determining which members of the medical staff were qualified to supervise in the ED. Reference deficiency written under Tag A1101

Based on interview, it was determined that the hospital did not have processes in place to ensure integration with other departments of the hospital, specifically the Urgent Care Clinic. The hospital's failure resulted in a lack of a written policy and procedure regarding how patients from the Urgent Care Clinic were referred to the hospital's Emergency Department. Findings include: On 5/25/2016, at 11:30 AM, the ED Medical Director was asked to describe the process for referrals from the Urgent Care Clinic to the ED. The Medical Director stated that the process was for the physician in the Urgent Care Clinic to call the ED physician directly to discuss the patient's referral. On 5/25/2016, a staff physician in the ED was asked to describe the process for referrals from the Urgent Care Clinic to the ED. The physician described the same process as the Medical Director. On 5/25/2016, the Clinical Director for ED Services stated that the hospital did not have a written policy and procedure for referral to the hospital's ED. The Director acknowledged that such a policy would provide clinic staff with guidance on appropriate transport of patients from the Urgent Care Clinic, including method of transfer and safety measures to be taken, as well as assist the ED with triage of patients.

Based on interview and review of hospital documents, it was determined that the hospital failed to assure that the Emergency Department (ED) supervised by a qualified member of the medical staff. The hospital's failure to do so resulted in the Governing Body not determining which members of the medical staff were qualified to supervise in the ED. Reference deficiency written under Tag A1101 Findings include: On May 24, 2016, at 1:30 PM, the Director of Medical Staff Services was interviewed and asked to provide documentation that the medical staff had defined the qualifications of medical staff. The Director was unable to provide that documentation. The Director was asked to provide a copy of the job description and was unable to provide that documentation. The Director provided a portion,pages 4 & 5, of the contract between the contracting physician's group and the hospital, which outlined job duties. The document did not specify the name of the hospital; did not specify what board-certification the medical director must have, or if board certification was required, and did not specify the amount, or type, of experience the medical director must have. The document did not have a date the job description was effective, when the document would be reviewed, or a signature. The Medical Director was interviewed on May 24, 2016 and stated that s/he had board certification in Family Medicine (verified by review of the physician's credentialing file). The Medical Director stated that the hospital accepted physicians who were board-certified in either Family Medicine or Emergency Medicine, and there was one ED physician who was board-certified in Internal Medicine and had been "grandfathered" in. The Medical Director provided an extensive description of how ED physicians were supervised and how quality assurance processes were carried out; however, the Medical Staff had not defined the required qualifications for the Medical Director.