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Based on review facility policy and procedure, and staff interview (EMP), it was determined that the facility failed to comply with §489.24 and failed to adopt and enforce polices and procdures to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

Findings include:

A review of policies and procedures on May 25, 2017, failed to include a facility policy to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).

1) Interview with EMP1 on May 25, 2017, at approximately 1:30 PM revealed that the facility did not have an EMTALA policy. Further interview indicated, "We do not have a policy on EMTALA specifically."

Based on observations and staff interviews (EMP), it was determined that facility failed to post conspicuously in the emergency department or in places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than the traditional emergency departments, a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings include:

1. Tour of the Emergency Department (ED) on May 24, 2017, at approximately 1:30 PM, revealed one direct entrance into the ED and one entrance from inside the hospital from the main lobby. Continued tour revealed a third ambulance only entrance. All three entrances failed to include the Emergency Medical Treatment and Active Labor Act (EMTALA) signs or information.

2. During an interview on May 25, 2017, at approximately 10:30 AM, EMP1 confirmed that there were no signs at any of the Emergency Department entrances regarding the Emergency Medical Treatment and Active Labor Act.