Oasis Behavioral Health Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51960 Based on reviews of review of hospital policies and procedures, medical records and staff interviews, it was determined that the Hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, the responsibilities of Medicare participating hospitals in emergency cases as evidenced by: A2408: The Hospital failed to implement and enforce Hospital policy for screening of patients to ensure a delay in treatment and examination did not occur. A2409: The Hospital failed to implement and enforce Hospital policy that specifies the process by which the Hospital coordinates transfers to another facility. These deficient practices can result in a delay in care and patient harm, and resulted in the facilities failure to meet the responsibilities of Medicare participating hospitals in emergency cases.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 51960 Based on review of hospital policy and procedures, hospital documents, medical records, and employee interview, it was determined the Hospital delayed treatment for nine (9) of 20 patients who presented to the Hospital seeking treatment. Failure to provide timely treatment poses the potential risk that a patient, determined to have an emergency medical condition, will not receive necessary treatment. Findings include: Hospital policy titled “Patient Transfer to Another Facility, PS 160,” Policy #16156893, Last revised 05/2023, revealed “ ...1. An appropriate screening examination should be provided to the individual by Qualified Medical Personnel (QMP), to determine the treatment needs of the individual and whether an emergency medical and/or psychiatric condition exists....” Hospital policy titled “EMTALA Compliance,” Policy #17970669, Last revised 04/2020, revealed “ ...It is the intent of the Hospital to provide the following services to all individuals who present to the Hospital with a request for examination and/or treatment: Appropriate medical screening examination performed by a qualified medical practitioner (QMP)...in a non-discriminatory manner ...and if the QMP determines a possible emergent medical condition exists then the Hospital will provide either: Within the capabilities of the hospital, further medical examination and treatment, as may be required to stabilize the medical condition; or Transfer the individual to another facility in accordance with applicable laws and regulations;....” A total of 20 patient medical records were randomly selected for review from the Hospital ’ s EMTALA Log. Nine (9) out of 20 medical records and related Hospital documents revealed the following: Patient #1 Hospital document titled “EMTALA Log September 02, 2025,” revealed “...Arrival Time ...15:29 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...09/02/2025 17:10 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ....” Patient waited one (1) hour and forty-nine (49) minutes. Patient #5 Hospital document titled “EMTALA Log September 20, 2025,” revealed “...Arrival Time ...12:45 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...09/20/2025 16:10 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ...Patient meets criteria for Emergent Medical Condition based on risk related to intoxication ...Yes ....” Patient waited three (3) hours and twenty-five (25) minutes. Patient #6 Hospital document titled “EMTALA Log September 25, 2025,” revealed “...Arrival Time ...18:15 ...Emergency Psychiatric Medical Condition ...No ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...09/25/2025 23:01 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ....” Patient waited four (4) hours and forty-six (46) minutes. Patient #7 Hospital document titled “EMTALA Log September 26, 2025,” revealed “...Arrival Time ...3:05 ...Emergency Psychiatric Medical Condition ...No ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...09/26/2025 08:10 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...No ....” Patient waited five (5) hours and five (5) minutes. Patient #11 Hospital document titled “EMTALA Log October 28, 2025,” revealed “...Arrival Time ...16:31 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...10/28/2025 18:50 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ...Patient meets criteria for Emergent Medical Condition based on risk related to intoxication ...Yes ....” Patient waited two (2) hours and nineteen (19) minutes. Patient #12 Hospital document titled “EMTALA Log November 6, 2025,” revealed “...Arrival Time ...16:30 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...11/6/2025 18:30 ...Patient meets criteria for Emergent Medical Condition based on physical finding ...Yes ...Patient meets criteria for Emergent Medical Condition based on risk related to intoxication ...Yes ....” Patient waited two (2) hours. Patient #14 Hospital document titled “EMTALA Log November 14, 2025,” revealed “...Arrival Time ...19:24 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...11/14/2025 20:29 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ....” Patient waited one (1) hour and five (5) minutes. Patient #15 Hospital document titled “EMTALA Log November 18, 2025,” revealed “...Arrival Time ...22:42 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...11/18/2025 02:19 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ....” Patient waited three (3) hours and thirty (37) minutes. Patient #20 Hospital document titled “EMTALA Log December 1, 2025,” revealed “...Arrival Time ...21:08 ...Emergency Psychiatric Medical Condition ...Yes ....” Medical record document titled “EMTALA - Medical Screening Examination,” revealed “ ...Date/Time ...12/1/2025 22:53 ...Patient meets criteria for Emergent Medical Condition based on risk of imminent harm to self/other due to psych. conditions ...Yes ....” Patient waited one (1) hour and forty-five (45) minutes. Employee #8 confirmed in an interview conducted on December 10, 2025 that the hospital ’ s goal is to screen patients who present to the hospital for an emergency medical condition “within 30 minutes” of arrival. Employee #8 further confirmed that the aforementioned medical screening examinations for Patients #1, #5, #6, #7, #11, #12, #14, #15 and #20 were all documented being over one (1) hour from the patient ’ s arrival per the Hospital ’ s EMTALA Log.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 51960 Based on a review of Hospital policy and procedures, patient medical records, associated document requests, and employee interviews, it was determined that the Hospital failed to implement and enforce the Hospital policy that specifies the process by which the Hospital coordinates patient transfers. This deficient practice poses a potential risk of patient harm when the coordination of patient care activities for patient transfers is not executed pursuant to hospital policy. Findings include: Hospital policy titled “Patient Transfer to Another Facility, PS 160,” Policy #16156893, Last revised 05/2023, revealed “ ...2. The patient should be examined and evaluated by a physician prior to transfer. If a physician is not immediately available, the physician on call or other available physician should be contacted by the nursing staff provided with a full telephone report of the patient ’ s clinical condition. The physician may give a telephone order for transfer without a personal examination if he/she determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination would be detrimental to the patient by unnecessarily delaying the transfer and further treatment ...1. The physician or QMP should directly communicate with the receiving facility ...2. The QMP is responsible to facilitate transfer and secure acceptance by a receiving facility, which provides treatment appropriate to the clinical condition of the patient ...5. The Transfer Summary form should be completed, including the certification statement that the benefits of transfer outweigh the risks, and should be signed by (i) the physician or his/her designee and (ii) an administrative representative of the facility. If the certification is provided by Qualified Medical Personnel because of physician unavailability at the time of transfer, the physician is required to sign the certification on the Transfer Summary as soon as possible....” A total of 20 patient medical records were randomly selected for review from the Hospital ’ s EMTALA Log. Ten (10) out of 20 medical records and related Hospital documents revealed the following: Patient #1 Hospital document titled “EMTALA Log September 2, 2025,” revealed “...Arrival Time ...15:29 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...20:54 ... Disposition ...911 called ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the name and signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025, for Patient 1 ’ s transfer order. None was provided. Patient #4 Hospital document titled “EMTALA Log September 19, 2025,” revealed “...Arrival Time ...17:04 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...17:50 ... Disposition ...911 called for Medical Emergency ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the name and signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025, for Patient 4 ’ s transfer order. None was provided. Patient #5 Hospital document titled “EMTALA Log September 20, 2025,” revealed “...Arrival Time ...12:45 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...19:32 ... Disposition ...Transferred/No Capacity ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. Line number 8 and line number 9 list the same name as the receiving physician and the transferring physician. In addition, the “Physician Certification” was not filled out, though the patient had an identified Emergency Medical Condition that was not documented to have been stabilized before transfer. A request was made on December 10, 2025, for Patient 5 ’ s transfer order. None was provided. Patient #8 Hospital document titled “EMTALA Log October 5, 2025,” revealed “...Arrival Time ...11:53 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...19:14 ... Disposition ...Stabilized and transferred ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address, as well as the name of the receiving hospital ’ s contact person accepting the transfer. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, per hospital policy. A request was made on December 10, 2025, for Patient 8 ’ s transfer order. None was provided. Patient #9 Hospital document titled “EMTALA Log October 10, 2025,” revealed “...Arrival Time ...15:13 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...16:25 ... Disposition ...911 called ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the name and signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025, for Patient 9 ’ s transfer order. None was provided. Patient #12 Hospital document titled “EMTALA Log November 6, 2025,” revealed “...Arrival Time ...16:30 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...19:51 ...Disposition ...Stabilized and transferred ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025 for Patient 12 ’ s transfer order. None was provided. Patient #13 Hospital document titled “EMTALA Log November 10, 2025,” revealed “...Arrival Time ...10:19 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...16:00 ...Disposition ...Stabilized and transferred ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address, as well as the name of the receiving hospital ’ s contact person accepting the transfer. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, per hospital policy. A request was made on December 10, 2025 for Patient 13 ’ s transfer order. None was provided. Patient #14 Hospital document titled “EMTALA Log November 14, 2025,” revealed “...Arrival Time ...19:24 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...21:46 ...Disposition ...Stabilized and transferred ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025 for Patient 14 ’ s transfer order. None was provided. Patient #17 Hospital document titled “EMTALA Log November 23, 2025,” revealed “...Arrival Time ...10:58 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...11:46 ...Disposition ...911 called ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. Line 10 did not have the signature of the transferring hospital administration/staff who contacted the receiving hospital. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the name and signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025 for Patient 17 ’ s transfer order. None was provided. Patient #19 Hospital document titled “EMTALA Log December 5, 2025,” revealed “...Arrival Time ...19:45 ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...20:24 ...Disposition ...911 called ...Departure Mode ...Ambo ....” Medical record document titled “Memorandum Of Transfer (EMTALA),” revealed “...INSTRUCTIONS ...1. Section A must be completed by Transferring Hospital when an emergency medical condition exists ....” Section A was not filled to completion and was missing the transferring hospital ’ s name, main phone number, and address. In addition, the “Physician Certification” did not have an administrative representative ’ s signature, nor the signature of the Consulting Physician, who was not present at the time of transfer, per hospital policy. A request was made on December 10, 2025 for Patient 19 ’ s transfer order. None was provided. Employee #8 confirmed in an interview conducted on December 10, 2025 that the aforementioned Memorandum Of Transfers were not completed per Hospital policy and there were no physician orders for transfer for review.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 49638 Based on review of hospital policy and procedure, document request, personnel records and employee interview, it was determined the hospital failed to establish formal in-service education requirements for EMTALA training for all employees. This deficient practice could result in personnel not being adequately trained in a manner which could result in inappropriate patient placement and/or patient harm. Findings Include: A review of facility policy, titled, “Orientation and Training, policy #HR 006, reviewed 03/15/2023, revealed “ ...Oasis Behavioral Health provides comprehensive orientation and training to meet all applicable federal and state regulations and requirements ...as well as ongoing requirements necessary to ensure individuals are able to fully perform the key functions of their role ....” Requests were made from January 22, 2025 through January 24, 2025, for facility policy and procedure regarding an EMTALA training program, identifying which staff are required to take the training, and the frequency of the training. None was provided. Employee #11 confirmed in an interview on January 24, 2025, that the facility does not have policy and procedure regarding an EMTALA training program that specifies which staff are required to take the training, and the frequency of the training.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 49638 Based on review of hospital policy and procedure, hospital documentation, medical record request and employee interview, it was determined that the hospital failed to ensure that a medical record for two patients was established & maintained. This deficient practice poses the risk of patient treatment not being accurate, timely and of continuity of care being compromised. Findings include: Policy titled “EMTALA Compliance,” Policy #17302486, last revised April, 2020, revealed “...It is the intent of the Hospital to provide the following services to all individuals who present to the Hospital with a request for examination and/or treatment:...Appropriate medical screening examination performed by a qualified medical practitioner (QMP)....” Policy titled “Medical Screening and Assessment, PC004,” Policy #16156497, last approved March 2023, revealed “...It is the policy of Oasis Behavioral Health (OBH) to provide a medical screening examination (MSE) to any individual who presents at the hospital seeking treatment on an urgent basis....” Document titled “EMTALA Log” revealed the following: Patient #3 arrived at the facility on December 13, 2024 at 02:30, “Arrival Mode ...Car ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...03:50 ...Disposition ...911 called ....” Patient #4 arrived at the facility on December 13, 2024 at 20:45, “Arrival Mode ...Car ...Departure Time ...21:15 ...Disposition ...Lacks acuity and referred ....” Requests were made on January 22, 2025 through January 24, 2025 for medical records and any documentation to support the above assessments and referrals for Patients #3 and #4. None were provided. Employee #5 confirmed in an interview on January 22, 2025 through January 24, no medical record or additional documentation for either Patient #3 or Patient #4 was available for review at the time of the survey.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 49638 Based on review of hospital policy and procedure, hospital documentation, medical record request and employee interview, it was determined that the hospital failed to ensure a medical screening exam (MSE) was completed for patients coming to the facility to determine whether or not an emergency medical condition exists. This deficient practice poses a potential risk to the health and safety of patients if life-threatening or potentially life threatening conditions are not recognized and stabilizing treatment provided. Findings include: Policy titled “Admission Procedure (Intake),” Policy #17302117, last revised August 2023, revealed “...When a patient arrives at the facility and requests an examination or treatment of a medical or psychiatric condition, a Medical Screening will be completed without delay to determine whether an emergency medical condition exists....” Policy titled “EMTALA Compliance,” Policy #17302486, last revised April 2020, revealed “...It is the intent of the Hospital to provide the following services to all individuals who present to the Hospital with a request for examination and/or treatment:...Appropriate medical screening examination performed by a qualified medical practitioner (QMP)....” Policy titled “Medical Screening and Assessment, PC 004,” Policy #16156497, last approved March 2023, revealed “...It is the policy of Oasis Behavioral Health (OBH) to provide a medical screening examination (MSE) to any individual who presents at the hospital seeking treatment on an urgent basis....” Document titled “EMTALA Log” revealed the following: Patient #3 arrived at the facility on December 13, 2024 at 02:30, “Arrival Mode ...Car ...Emergency Psychiatric Medical Condition ...Yes ...Departure Time ...03:50 ...Disposition ...911 called ....” Patient #4 arrived at the facility on December 13, 2024 at 20:45, “Arrival Mode ...Car ...Departure Time ...21:15 ...Disposition ...Lacks acuity and referred ....” Requests were made on January 22, 2025 through January 24, 2025 for MSEs for Patients #3 and #4. None were provided. Employee #5 confirmed in interviews conducted on January 22, 2025 through January 24, 2025 that no MSEs were available for review for Patients #3 or #4 at the time of the survey.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 48110 Based on record reviews, observations, and staff interviews, it was determined the administrator failed to ensure the seclusion of a patient (Patient #16) occurred in a seclusion room approved by the Department. This deficient practice poses the risk of patients being confined and secluded in a room that is not safe and designed for seclusion, and causes confusion to patients whether they are allowed to leave the room. Findings include: Review of the hospital’s Arizona Department of Health Services (AZDHS) licensing file revealed no documentation that the Department approved the small day room in the Cholla unit as a seclusion room. Patient #16’s medical record dated 04/16/2024 identified a nursing note, and it revealed: “ ...Patient came out of [her] room to engage with peers in hallway refusing redirection by staff. Patient began to hit [her] head against the wall. Staff restrained patient and transferred [her] to Cholla ....Patient secluded to stay in small day room at 2106 and [she] proceeded to pick at scabs making [herself] bleed and threaten staff when preventing [her] from continuing ....” Patient #16’s medical record dated 04/16/2024 revealed a seclusion order for two hours. Patient #16’s medical record dated 04/16/2024 identified a behavioral seclusion restraint flowsheet, and it revealed Patient #16 was placed in seclusion in the small day room of the Cholla unit at 2106 hours, and released at 2118 hours. Observations on tour of the Cholla unit on 06/03/2024 revealed the small day room required key access to enter. The room had three non-reclining chairs, glass window across the room from the door, and walls that were not padded. Employee #1 confirmed during an interview on 06/03/2024 that Cholla unit was empty with no inpatients on 04/16/2024. Employee #1 also confirmed Patient #16 would get agitated surrounded by peers, and often times need time alone away from their peers. Employee #1 and Employee #4 confirmed Patient #16 was removed from their peers, and secluded in the small day room of the Cholla unit.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse, the trained registered nurse must consult the attending physician or other licensed practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation. This Standard is not met as evidenced by: 48110 Based on record reviews and staff interview, it was determined the hospital failed to ensure trained registered nurses, who conducted the face-to-face evaluation after two restraint/seclusion episodes, consulted with the attending physician as soon as possible for a patient (Patient #16). This deficient practice poses a risk to the health and safety of patients when the attending physician is not consulted of the patient’s medical and behavioral condition after a restraint/seclusion episode. Findings include: Policy titled, “Restraint”, revealed: “ ...Procedure ...8. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ....” Policy titled, “Seclusion”, revealed: “ ...Procedure ...7. A practitioner or registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status ....” Document titled, “Rules and Regulations of the Medical Staff”, revealed: “ ...9.2 Restraints or Seclusion Used for Emergency Behavior Management Reasons ...A Practitioner or specifically trained registered nurse must see and evaluation the need for the Restraints or Seclusion within one (1) hour after initiation of the Restraints or Seclusion and upon being released from Restraints or Seclusion ....In the event that a registered nurse conducts the evaluation required by this section, the Attending Physician must be consulted as soon as possible ....” Patient #16’s medical record dated 04/16/2024 revealed they were placed in physical restraint at 2104 hours, and seclusion from 2106 to 2118 hours. Review of the face-to-face evaluation revealed it was performed on 04/16/2024 at 2118 hours by a registered nurse. Further review of the face-to-face evaluation revealed no documentation that the attending physician was consulted after the evaluation was completed. Patient #16’s medical record dated 04/17/2024 revealed they were placed in physical restraint at 2024 hours, and seclusion from 2025 to 2220 hours. Review of the face-to-face evaluation revealed it was performed on 04/17/2024 at 2124 hours by a registered nurse. Further review of the face-to-face evaluation revealed no documentation that the attending physician was consulted after the evaluation was completed. Employee #4 confirmed during an interview conducted on 05/31/2024 that there was no documentation the registered nurses, who performed the face-to-face evaluations on Patient #16, consulted with the attending physician after the completion of the evaluations.”