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Based on review of policies and procedures, hospital bylaws, rules and regulations, interviews, it was determined the hospital failed to comply with 489.24. as evidenced by:

1. A2406 489.24(a) Medical Screening Examination:

a. Failure to determine who is qualified by hospital bylaws or rules and regulations to conduct a medical screening examination.

Based on observation during tour, policies and procedures and interview with staff, it was determined the hospital failed to conspicuously post the rights of individuals identified under section 1867, and information whether the hospital participates in the Medicaid program, at the ambulance entrance to the main ED.

Findings include:

The hospital policy titled Emergency Medical Treatment and Labor Act (EMTALA) Compliance, required: "...Signage: FMC will post a sign in its dedicated Emergency Department(s) and other waiting areas of the hospital that states the rights of persons under EMTALA and whether FMC participates in the Medicaid program...."

A tour of the two dedicated ED's was taken on 12/07/10, at 1000 hours. The main ED ambulance entrance did not have signage posting the rights and whether the hospital participates in the Medicaid program. The individual rooms did not have signage for patients entering via the ambulance entrance that could have been seen. Employee #9 confirmed the findings on 12/07/10, at 1030 hours.

Based on review of the dedicated ED logs, policies and procedures, and interview with staff, it was determined the hospital failed to maintain a central log on each individual coming to the ED seeking assistance and the ED logs did not contain the required elements as evidenced by:

1. Pt #1 came to the ED on 10/04/10, with a swollen right foot and purple toes,seeking care and was told there was nothing that could be done for him/her, Pt #1 was not entered into the ED log; and

2. the OB triage log did not contain the following criteria; whether the patient(s) refused treatment, was refused treatment, treated stabilized and transferred, or discharged; and the ED log did not contain whether the patient(s) were stabilized and transferred, or were refused treatment.

Findings include:

The hospital policy titled Emergency Medical Treatment and Labor Act (EMTALA) Compliance, required: "...Dedicated Emergency Department Log: FMC will maintain a list of each person covered by EMTALA who comes to FMC's dedicated Emergency Department(s). This log must state, at a minimum, whether the patient refused treatment, was refused treatment, was transferred, was admitted and treated, stabilized and transferred, or discharged. FMC may keep a separate log for each dedicated Emergency Department...."

1. The patient (Pt #1) was first seen in the ED on 09/30/10, at 1127 hours, with complaints of falling and injuring her right ankle. The patient admitted to drinking heavily prior to arrival. She received a medical screening examination, x-rays, pain medication, anti-nausea medications and had a posterior and sugar tong splint to the lower left extremity.

Pt #1 was discharged at 1800 hours with the following written instructions: "...If my condition worsens, I will call my doctor or immediately return to the Emergency Department...Patient Education Materials: No instructions were provided...Follow Up With: Guidance Center The (sic)...Comments: Diagnosis: Non-Displaced Right Distal Fibula Fracture Avoid Alcohol Follow Up With Dr. (name of orthopedic physician)...(address and phone number)...." Pt #1 signed the form.

The patient was discharged to the "Intake Treatment Unit" and voluntarily went to the Guidance Center for alcohol rehabilitation upon discharge from the ED.

The following information is documented in the medical record for the 09/30/10 visit: "...10/07/10, 03:33 pm...Late entry: Pt presented to ED triage window on 10/04/10 asking advice regarding her ankle fracture from 9/30/10. She was seen and treates (sic) here for same complaint on 30th and dc'd in pot splint. Presents at this time w splint intact but foot swollen...10/07/10, 03:35 pm...continuation of note; Toes pink w brisk refill. Pt was not given instructions regarding fracture and splint and crutches on the 30th and was given those specific instr's on 10/4 by this RN. Pt came in on crutches but was full wgt bearing and informed...10/07/10 03:39 pm...continuation; this RN that she had limited opportunity to elevate her ankle. She declined signing into the ED at that time and encouraged to return if she changed her mind, and not better or if condition worsened. She left w further dc instr's...."

The ED log for 10/04/10, did not include Pt #1.

Employee #3 confirmed during an interview on 12/08/10, at 1400 hours, that Pt #1 should have been entered into the ED log.

2. The dedicated ED logs were reviewed for a 6 month period, starting in June 2010 through November 2010.

The main ED log was an electronic log, it did not include documentation of whether or not patients were treated stabilized and transferred.

Employee # 3 and #4 confirmed the above on 12/08/10 at 1400 hours.

The OB ED log was a handwritten daily log. November 24-30, 2010, was reviewed with Employee #8. For those days, there were 24 patients that arrived for a medical screening examination. Nineteen (19) of those patients identified on the log did not include the disposition. Employee #8 confirmed the findings and verified the log did not include documentation whether the patient(s) refused treatment, were refused treatment, or were treated stabilized and transferred.