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Based on interview and record review the facility failed to comply with 489.24. See Tag C 2401.

Based on interview and record review the facility failed to report to CMS or the State Agency within 72 hours of believing they may have received an individual who was referred to the facility with an unstable emergency medical condition. Findings include:

On 8/19/2010 at approximately 1500 an interview with the Risk Manager revealed that the facility was aware that a potential patient had been identified by way of an "Variance/Concern Report" filled out by Physician #1 on 7/17/2010 and received by the Nurse Manager and Risk Manager on 7/19/2010.

On 8/23/10 at approximately 1030 an interview with the Nurse Manager revealed that the facility did contact the sending facility regarding the potential EMTALA violation and agreed to meet and self report together to CMS. The Nurse Manager stated "I didn't realize there was a certain timeframe to report."

Based on record review the facility failed to ensure an adequate medical screening exam was performed to rule out an emergency medical condition for 1 of 3 (#16) pregnant patients that presented to the emergency department. Findings include:

On 8/24/10 at approximately 1630 during a review of patient #16's medical record the following documentation was missing to determine if an emergency medical condition was ruled out:

1)On the form titled "Emergency Record/Outpatient Record" which contains physician's notes
A. The section titled "Condition on Discharge" was blank
B. The section for disposition was checked "home"
C. The section for the discharge diagnosis it was written "Pelvic pain"

2)The physician's dictated "Emergency Room Report" had documented
A. "As her pelvic pain has subsided, it was assumed it wasn't labor..."
B. "A pelvic exam was not performed, as it was not deemed necessary after her pain subsided."

3)On the form titled "Emergency Nursing Record" it was documented
A. "Physician #1 in to see pt. says "pelvic exam isn't necessary."
B. "...pain down to "4" on 0-10 scale"
C. The section titled "Condition Upon Discharge" indicated "improved" and pain "4/10"