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Based on review of facility policy and procedures, medical staff bylaws, review of the central log and staff interviews, the facility failed to ensure staff followed the following policies related to EMTALA. The central log failed to include Patient 7 who came to the hospital for emergency treatment. Staff failed to provide Patient 7 with a Medical Sceening Examination. The facility failed to ensure the required signage notifying patients of their rights under EMTALA were posted at the entrance, waiting room, and treatment areas. A sample of 20 records from October 2010 to March 2011 were selected for review. Findings are:

A. Interview with the Director of Nursing (DON) on 4/4/11 at 2:10 PM confirmed Patient 7 was not included in the Central Log. The DON stated staff did not know the patient's name or enter information about her request for care in the log. The DON confirmed this is "a problem, they could have used 'Doe'."

Review of a facility document titled "Appendix to Medical Staff Rules and Regulations" last revised 7/07 states "A Central log shall be maintained on each individual who comes to the Hospital seeking assistance, recording whether he or she refused treatment, was refused treatment, was stabilized and transferred or was discharged." See also C2405.

B. Interview with Registered Nurse (RN)-A on 4/5/11 at 1:05 PM revealed Patient 7 was in a truck parked outside the entrance to the hospital on 3/28/11. The hospital entrance doorbell rang around 5:45 AM. RN-C answered the door and a man stated "My girlfriend is having contractions." RN-A asked the man "where their doctor was located." The man replied "Kearney". RN-A said to the man "We don't deliver babies often, there is not a Maternity Ward [here], it's [an] Emergency Room." The man then said "The baby is coming." RN-C did not go out to the vehicle and never saw the patient. The nurse left the entrance area to get other staff and upon returning the man said that they were going to Holdredge, a town located 20 minutes away. The staff did not provide Patient 7, a woman in labor, with a medical screening examination (MSE). See also C2406.

Review of facility policy titled "Emergency Room Guidelines" last revised 10/7/04 states:
1. Emergency Room buzzer is answered by nursing personnel on all shifts.
2. Escort patient to appropriate treatment location. Use wheelchair or stretcher, if needed.
3. RN to assess patient in accordance with EMTALA policy. Notify medical staff member on call, as indicated. Other personnel may assist with supportive measures.

Review of the "Appendix to Medical Staff Rules and Regulations" last revised 7/07 under the section titled "Medical Screening Examination" states that "For any individual arriving at the Emergency Department, and on whose behalf a request for examination or treatment for a medical condition is made, or if a prudent layperson observer would believe that the individual needs examination or treatment for an emergency medical condition, an appropriate medical screening examination shall be provided within the capabilities of the Emergency Department (and ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition exists."

C. Observation tour with the administrator on 4/5/11 at 2:40 PM found the facility has large well-lit signs directing emergency patients to the hospital's main entrance. A patient would enter the hospital through a sliding door into an enclosed entry way where there is another sliding door which is kept locked at night. This sliding door has a buzzer doorbell with directions to push the buzzer for assistance. There is no signage notifying a patient of their rights related to EMTALA in the entry area, admitting/registration area, waiting room or treatment rooms. The only EMTALA sign posted is located on a side hallway of the Emergency Room (ER) that is not clearly visible to patients entering the ER from the front entrance of the hospital or the ambulance entrance. The hospital administrator confirmed this finding.

Review of facility policy titled "Appendix to Medical Staff Rules and Regulations" last revised 7/07 under the section titled "Signs" states that "A sign shall be posted conspicuously in the Emergency Department specifying the rights of individuals under Social Security Act Section 1867 with respect to examination and treatment for emergency medical conditions." The policy fails to specify that signs are to be posted in places likely to be noticed by all individuals entering the ER, as well as the entrance, admitting area, waiting room and treatment area. See also C2402.

Based on observation tour of the facility, staff interview and review of facility policies, the facility failed to ensure signage notifying patients of their rights related to EMTALA (Emergency Medical Treatment and Labor Act) were posted conspicuously in the main entrance area to the hospital, admissions/registration area, Emergency Department (ED) waiting room or treatment rooms. Findings are:

A. Observation tour with the administrator on 4/5/11 at 2:40 PM found the facility has 2 large well-lit signs outside the hospital directing emergency patients to the hospital main entrance. At the main entrance a patient enters through a sliding door into an enclosed entry way where there is another sliding door which is kept locked at night. The door has a buzzer doorbell with directions to push the buzzer for assistance. There is no signage notifying a patient of their rights related to EMTALA in the entry area, admitting/registration area, waiting room or treatment rooms for the ER (Emergency Room). The only EMTALA sign is on a side hallway of the ER that is not clearly visible to patients entering the ER from the main entrance or the ambulance entrance. The administrator confirmed this finding during the tour.

Review of facility policy titled "Appendix to Medical Staff Rules and Regulations" last revised 7/07 under the section titled "Signs" states that "A sign shall be posted conspicuously in the Emergency Department specifying the rights of individuals under Social Security Act Section 1867 with respect to examination and treatment for emergency medical conditions." The policy fails to specify that signs are to be posted in places likely to be noticed by all individuals entering the ER, as well as the entrance, admitting area, waiting room and treatment area.

Based on review of the central log, facility policy review and staff interview, the facility failed to ensure Patient 7 who presented to the hospital for emergency treatment was included in the central log. A sample of 20 records from October 2010 to March 2011 were selected for review. Findings are:

A. Interview with Registered Nurse (RN)-A on 4/5/11 at 1:05 PM revealed Patient 7 was brought to the hospital and a male companion requested care on her behalf on 3/28/11 at approximately 5:45 AM.

Review of the central log for 3/28/11 found no entry related to this patient who did not receive a medical screening examination.

Interview with the Director of Nursing (DON) on 4/4/11 at 2:10 PM confirmed Patient 7 was not included in the Central Log. The DON stated staff did not know the patient's name or enter information about a request for her care in the log. The DON confirmed this is "a problem, could have used 'Doe'."

Review of a facility document titled "Appendix to Medical Staff Rules and Regulations" last revised 7/07 states "A Central log shall be maintained on each individual who comes to the Hospital seeking assistance, recording whether he or she refused treatment, was refused treatment, was stabilized and transferred or was discharged." See also C2406.

Based on record review, staff interviews, and review of the facility's internal investigation documents, the facility failed to provide a woman in labor (Patient 7) with a Medical Screening Examination. A sample of 20 records from October 2010 to March 2011 were selected for review. The facility self-reported a possible EMTALA violation related to Patient 7 on 3/31/11. Findings are:

A. Interview with Registered Nurse (RN)-A on 4/5/11 at 1:05 PM revealed Patient 7 was in a truck parked outside the entrance to the hospital on 3/28/11. RN-A related the hospital entrance doorbell rang around 5:45 AM. RN-C answered the door and a man stated "My girlfriend is having contractions." RN-A asked the man where their doctor was located. The man replied "Kearney". RN-A told the man "We don't deliver babies often, there is not a Maternity Ward [here], it's [an] Emergency Room." The man then said "The baby is coming." RN-C did not go out to the vehicle and never saw the patient. The nurse left the entrance area to get other staff and upon returning the man said that they were going to Holdrege, a town 20 minutes away. RN-A stated "I didn't know what to do when he turned to leave. I thought that since she didn't actually come into the hospital it wasn't a problem." RN-A stated "It didn't even cross my mind to go out to the car and see the woman." RN-A stated he/she had "no education during orientation or since on how to do an emergency delivery." RN-A had been employed at the hospital for 2 years, 2 months. RN-A also stated "In retrospect my telling him we don't do deliveries and had no Maternity Ward could be perceived by someone as encouragement to leave." The staff's failure to provide the pregnant woman with a Medical Screening Examination (MSE) placed her and her unborn baby at risk.

B. Review of the facility internal investigation included the transcript of a 911 call made on 3/28/11 at 5:44 AM specific to Patient 7. The transcript indicated Patient 7 stated "I'm in active labor on my way to Holdredge from Stamford on Hwy 381, 5 miles from Alma/on Hwy 183/Yeah 183 sorry stopped in Alma at the hospital and they said they didn't have the stuff for the baby, for us to go to Holdrege." An ambulance was dispatched by EMS to intercept the vehicle, and at 5:59 AM transported Patient 7 to the receiving hospital. The 911 transcript identified the ambulance arrived at the receiving hospital at 6:05 AM.

Review of the receiving hospital records for Patient 7 dated 3/28/11 revealed the patient was in active labor with her 4th child. The patient delivered an infant at 6:31 AM, 46 minutes after requesting treatment at Harlan County Health System.

C. Record review of facility policy titled "Emergency Room Guidelines" last revised 10/7/04 states:
1. Emergency Room buzzer is answered by nursing personnel on all shifts.
2. Escort patient to appropriate treatment location. Use wheelchair or stretcher, if needed.
3. RN to assess patient in accordance with EMTALA policy. Notify medical staff member on call, as indicated. Other personnel may assist with supportive measures.

Review of the "Appendix to Medical Staff Rules and Regulations" last revised 7/07 under the section titled "Medical Screening Examination" states that "For any individual arriving at the Emergency Department, and on whose behalf a request for examination or treatment for a medical condition is made, or if a prudent layperson observer would believe that the individual needs examination or treatment for an emergency medical condition, an appropriate medical screening examination shall be provided within the capabilities of the Emergency Department (and ancillary services routinely available to the Emergency Department) to determine whether or not an emergency medical condition exists."