United Regional Health Care System

“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: 45847 . Based on record review and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on record review and interview, Facility A failed to accept the appropriate transfer for 2 of 20 patients whose records were reviewed (Patient #4 and Patient #5) when the patients required a higher level of care and specialized facilities which Facility A had capacity and capability to provide. Facility A refused to accept Patient #4 and Patient #5 based on the sending facility’s refusal to sign a “Reciprocal Transfer Agreement”. Patient #4 was an 18-year-old female and Patient #5 was a 67-year-old male, and both had documented emergency medical conditions (EMCs) that required stabilization. . Refer to A-2411, §489.24(f) Recipient Hospital Responsibilities for additional information. .”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 45847 . Based on record review and interview, Facility A failed to accept the appropriate transfer for 2 of 20 patients whose records were reviewed (Patient #4 and Patient #5) when the patients required a higher level of care and specialized facilities which Facility A had capacity and capability to provide. Facility A refused to accept Patient #4 and Patient #5 based on the sending facility’s refusal to sign a “Reciprocal Transfer Agreement”. Patient #4 was an 18-year-old female and Patient #5 was a 67-year-old male, and both had documented emergency medical conditions (EMCs) that required stabilization. . Findings: Patient #4 Medical Record at Facility D, the sending hospital: Patient #4, an 18-year-old female, arrived at Facility D on 08/11/2025 at 9:36 PM with a chief complaint of bite/sting and stated complaint of suspected snake bite (page 31/72). The medical screening exam (MSE) was initiated at 9:06 PM. The History of Present Illness (HPI) documentation revealed that Patient #4 presented to the emergency department (ED) at Facility D with a suspected copperhead snake bite. Patient #4 stated ‘I can’t feel my toes’ and reported numbness extending ‘all the way up to my feet.’ The bite occurred approximately 20-30 minutes prior to her arrival (page 25/72). . The provider notes revealed that the ED provider called to [Facility B] who had only one antivenin and would be required to transfer the patient out as well. The ED provider then called [Facility A] for a transfer and spoke with [Staff A1] the Transfer Coordinator who wanted the “Reciprocal Transfer Agreement” signed before accepting the patient as a transfer. . The ED provider documented, “Neither I or my nursing staff could agree to this agreement due to [Facility D] having to take back an acute med surg patient. [Staff A1] said he could not take the patient if the paperwork is not completed. So, I initiated a call to [Facility C] and [Staff #C1] will accept the patient for transfer to his ED” (page 25/72). . The diagnosis at disposition: Toxic effect of venom of other snake, accidental, unintentional (page 1/72). Patient #4 was transferred via EMS to Facility C on 08/12/2025 at 12:47 AM (page 5/72). Facility A declined the transfer for Patient #4 due to Facility D’s ED provider not signing the Reciprocal Transfer Agreement. Facility A had both the capacity and capability to care for Patient #4. Patient #4 was subsequently transferred via EMS to a hospital in Oklahoma City, OK, [Facility C] which was 110 miles away. This resulted in an approximate 3-hour delay in care. . Patient #4 Medical Record at Facility A, the refusing hospital: Patient #4 does not have a complete medical record at Facility A due to the refusal of transfer. The document provided as a “medical record” for Patient #4 was entered by the Transfer Coordinator, Staff #A1, contained a birthdate and a date of “admit” of 08/11/2025. There was a blood pressure (BP) 134/102, pulse 113, respirations 36, temperature of 36.7 degrees Celsius, and oxygenation of 99% on room air at 8:33 PM documented by the Transfer Coordinator, Staff #A1, at the time of the transfer request (page 1-2/3). . Patient #4 Medical Record at Facility C was not received as requested as of 02/02/2026 at 3:21 PM. . Patient #5 Medical Record at Facility D, the sending hospital: Patient #5, a 67-year-old male, was admitted to the ED on 08/20/2025 at 10:08 PM with chief complaints of weakness (page 93/129). Patient #5 has a history of myelodysplastic syndrome (MDS), atrial fibrillation (a-fib), coronary artery disease (CAD), diabetes, and pacemaker, who presents to the ED with complaints of generalized weakness for the past two days. The medical screening exam began at 10:10 PM (page 76/129). The ED provider’s notes included, “ ... Attempted to transfer patient to [Facility A] where his oncologist/hematologist is located, but transfer was declined due to facility agreement issues ...It is noted that [Facility A] did have capability and capacity for the patient however declined based on our facility not signing a reciprocal agreement. I did express concern that they are higher level of care and the patient requires a higher level of care. They verbalized understanding and still declined ... Initially [Facility A] was contacted I did speak with the transfer coordinator. Transfer coordinator declined to accept due to lack of our facility signing a reciprocal administrative agreement. I did clarify with the transfer coordinator that they do have capability and capacity to care for the patient the transfer coordinator states that they do. I did state the patient does require a higher level of care and transfer coordinator understands this. He does ask me whether the patient is stable or unstable. I do state that the patient is currently stable. However does require higher level of care and the transfer coordinator explicitly states that they are unable to accept the patient without signed documentation of reciprocal agreement. I do state that this is in violation of the EMTALA regulations ...” (page 64-65/129). . Facility A declined Patient #5’s transfer due to Facility D’s ED provider not signing the Reciprocal Transfer Agreement. Facility A had the capacity and capability to treat Patient #5. Patient #5 was subsequently transferred to another hospital, Facility B. . Patient #5 Medical Record at Facility A, the refusing hospital: Patient #5 does not have a complete medical record at Facility A due to the refusal of transfer. The document provided as a “medical record” for Patient #5 was entered by the Transfer Coordinator, Staff #A1, and contained a birthdate and date of “admit” of 08/20/2025. There was no time, diagnosis, or any medical information other than a blood pressure (BP) 122/83, pulse 95, respirations 18, temperature of 36.7 degrees Celsius, and oxygenation of 100% on room air at 11:11 PM documented by the Transfer Coordinator, Staff #A1, at the time of the transfer request (page 1-2/3). . Patient #5 Medical Record at Facility B, the receiving hospital: Patient #5 was transferred/admitted on 08/20/2025 via EMS at 9:09 PM (page 49/96). Patient #5 was monitored, tested, and medicated until he was discharged home on 08/28/2025 at 3:47 PM. The diagnosis at disposition: anemia secondary to MDS, weakness, cough, paroxysmal atrial fibrillation, heart failure, refractory anemia, and other specified abnormal findings of blood chemistry (page 1/96). The patient was transferred to Facility B on 08/21/2025 at 9:16 AM. . During a review of Facility A’s log for “Incoming Transfers Denied - JUL-DEC 2025”, it was determined that 12 of 228 denied patient transfers requests were related to the Reciprocal Transfer Agreement not being signed by 9 different hospitals. The monthly breakdown is as follows: . July 2025: On page 6 of 18, a patient (MRN 850929) required a higher level of care and was denied a transfer from Facility E on 0/24/2025. (44 denials) On page 7 of 18: a patient (MRN 456019) required a higher level of care and was denied a transfer from Facility D on 07/31/2025. . August 2025: On page 8 of 18: a 2-year-old patient (MRN not on the log) with an acute sub-dural hematoma and a 3-4 mm midline shift requiring specialized care was denied a transfer from Facility F on 08/01/2025. (46 denials) On page 8 of 18: a patient (MRN 805684) with end-stage renal disease, pulmonary edema, and uncontrolled hypertension requiring specialized care was denied transfer from Facility G on 08/06/2025. . On page 9 of 18: a patient (MRN 637011) with anemia, atrial fibrillation with rapid ventricular response requiring specialized care was denied a transfer from Facility D on 08/20/2025. . September 2025: On page 10 of 18: a patient (MRN 624200) requiring a neurology consultation was denied transfer from Facility D on 09/02/2025. (54 denials) On page 11 of 18: a patient (MRN 853040) with jaundice and an elevated bilirubin at 10.4, CT and US were done. The requested transfer was to obtain an ERCP. The transfer from Facility B was denied on 09/04/2025. . On page 11 of 18: a patient (MRN 284653) with cauda equina, incontinence, and possible infection, needing an MRI was denied a transfer from Facility B on 09/12/2025. . On page 12 of 18: a patient (MRN 592720) post a ground level fall - imaging shows a right femur fracture and a periprosthetic fracture requiring surgery was denied a transfer from Facility B on 09/20/2025. . October 2025: On page 14 of 18: a patient (MRN 350283) with chest pain and new onset atrial fibrillation was denied a transfer from Facility H on 10/23/2025. (32 denials) November 2025: On page 15 of 18: a patient (MRN 58004) with a diagnosis of Cecum Mass-a Biopsy was performed- malignancy was found, care needs to be continued with (24 denials) oncology at Facility A was denied a transfer from Facility I on 11/04/2025. . December 2025: On page 17 of 18: a patient (MRN 385043) with symptomatic anemia was denied a transfer from Facility J on 12/05/2025. (28 denials) On page 17 of 18: a patient (MRN 857789) with hematemesis with history of esophageal varices was denied a transfer from Facility J on 12/15/2025. . The Reciprocal Transfer Agreement (RTA) Review: The RTA is a document that Facility A requires to be signed by a sending Facility before patients can be accepted. The document includes the following: [Facility A] agrees to accept the patient for temporary inpatient stay for the management of medical condition(s) that cannot be adequately managed at the Transferring Facility. . “ ...The Referring Facility will accept the patient back to its facility whether the patient still meets inpatient criteria for the purpose of ongoing acute care or for post-acute care discharge planning, in the event the patient does not require further hospitalization ... . ...In the event the Transferring Facility is unable to accept the return of the patient back to the Transferring Facility within no more than 48 hours due to bed capacity, resources, or personnel deficiencies, the Transferring Facility shall accept the return transfer of the patient immediately upon first availability of bed capacity, resources, and personnel and shall give priority to the patient subject to this Agreement ... . ...In the event the Transferring Facility is unwilling to accept return of the patient within 48 hours, the Transferring Facility guarantees to reimburse [Facility A] and the patient’s physician at [Facility A], for services or days that are denied or not covered by the patient’s insurer(s) at the insurer(s) customary reimbursement rate for the patient’s ongoing care.” . The RTA requires the “Signature of referring Physician”. . In accordance with the facility’s RTA guideline, the sending hospital must agree to accept back the patient they want to send even if he/she does not meet criteria to do so. This statement on the RTA includes “inpatient” requirements. The patients required transfers based on their emergency medical conditions which required stabilization. It had not been determined that an inpatient stay was needed, however the transfers were denied by Facility A. In addition, the RTA indicates that the sending hospital must agree to prioritize accepting back the patient being transferred within 48 hours. Additionally, Patient #1 and Patient #3, the ED provider was a mid-level provider, who do not have admitting privileges at Facility D, and cannot legally sign the RTA. . It was discovered during the tour of the ED on 01/13/2026 at 11:04 AM that Facility A’s average daily Census was 205 on 01/13/2026, which is a normal number for Facility A. The ED Census numbers provided coincide with an average number supporting that Facility A had capacity to treat Patients # 4 and #5. . The ED Census on the dates of patient transfer refusals that were due to the RTA were as follows: July 2025 5,740 ED patients for the month 195 ED patients on 07/24/2025 179 ED patients on 07/31/2025 . August 2025 5,718 ED patients for the month 178 ED patients on 08/01/2025 172 ED patients on 08/06/2025 198 ED patients on 08/11/2025 181 ED patients on 08/20/2025 . September 2025 5,856 ED patients for the month 195 ED patients on 09/02/2025 182 ED patients on 09/04/2025 176 ED patients on 09/12/2025 197 ED patients on 09/20/2025 184 ED patients on 09/29/2025 . October 2025 5,836 ED patients for the month 188 ED patients on 10/23/2025 . November 2025 5,585 ED patients for the month 186 ED patients on 11/04/2025 . December 2025 6,066 ED patients for the month 200 ED patients on 12/05/2025 188 ED patients on 12/15/2025 . Interviews: The Quality and Safety Director, Staff #14, was interviewed throughout the investigation and ended at 9:19 AM on 01/14/2026. During the interviews, Staff #14 indicated that the Reciprocal Transfer Agreement (RTA) had not been approved by any Federal agency prior to it being required by Facility A to be signed by other hospitals to approve transfers. Staff #14 indicated that the RTA has been in use at Facility A since August 2024 and was not a part of Facility A’s policies or bylaws approved by the Governing Body. .”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45847 . Based on record review and interview, the hospital failed to follow its emergency services policies and procedures for 1 of 20 patients (Patient #1) whose records were reviewed in that: 1. Patient #1 did not receive a pain score by nursing in accordance with the hospital’s Triage of the Obstetric Woman in the OBED [Obstetrical Emergency Department] policy. 2. Nursing did not follow the hospital’s Triage of the Obstetric Woman in the OBED [Obstetrical Emergency Department] policy for Patient #1 in accordance with the Maternal Fetal Index (MFTI) protocol when answering the MIFTI algorithm questions provided. 3. Patient #15 was not provided with an explanation of the individual the risks and benefits of refusing treatment in accordance with the Against Medical Advice (AMA) policy, and there was no documentation by nursing that the physician was notified of his intended departure. . Document Reviews: The facility’s Triage of the Obstetric Woman in the OBED, last reviewed and implemented on 01/15/2025, stated on page 1 of 8: “ ...3. DEFINITIONS AND CONSIDERATIONS: 1. Hospital-based obstetric (OB) or triage units generally provide four distinct activities to provide care for women who present for unscheduled evaluation. 1. Triage: a rapid systematic clinical assessment that focuses on the identification of problems and clinical needs and assigns priority of care based on acuity ...” . And on page 2 of 8: “ ...3. Women who are at less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the main emergency department. 4. Regardless of presenting complaint, care of the pregnant woman includes assessment of the fetus as part of the MSE ...” . The Maternal Fetal Triage Index (MFTI) is an algorithm contained in the “Facility’s Triage of the Obstetric Woman in the OBED policy” that provides triage levels for pregnant patients. The nurse is to answer “yes” or “no” to questions at each level of the algorithm. The MFTI triage levels are posted on the wall of the nurse’s station in the Facility’s ED. The MFTI triage levels are as follows: STAT/Priority 1 - Immediate, life-saving intervention needed for the mother or baby. If the nurse notices that the woman has symptoms such as STAT/PRIORITY 1 vital signs or compromise to the mother or fetus, she should answer “yes” to one of three questions: 1. Does the woman or fetus have STAT/PRIORITY 1 vital signs? 2. Does the woman or fetus require immediate lifesaving interventions? 3. Is birth imminent? One example of these conditions listed were: “Hemorrhaging” which is also known as bleeding. URGENT/Priority 2 - Severe symptoms or high-risk conditions that require prompt attention. If the nurse notices that the woman has symptoms such as a high-risk situation, she should answer “yes” to one of four questions: 1. Does the soman or fetus have URGENT/PRIORITY 2 vital signs? 2. Is the woman in severe pain without a complaint of contractions? 3. Is this a high-risk situation? 4. Will this woman and/or newborn require a higher level of care than institution provides? One of the example conditions listed was: “Active vaginal bleeding”. PROMPT/Priority 3 - Prompt attention is needed. If the nurse notices that the woman has symptoms such as complaints that could indicate early labor or abnormal vital signs, she should answer “yes to one of these two questions: 1. Does the woman or fetus have PROMPT/PRIORITY 3 vital signs? 2. Does the woman require prompt attention? The example conditions listed were all related to women who were ? 34 weeks or women not coping with labor or abnormal vital signs. NON-URGENT/Priority 4 - Patients presenting with something requiring non-urgent attention such as mild, common pregnancy discomforts. If the nurse notices that the woman has a condition requiring non-urgent attention, she should answer “yes” to the following question: 1. Does the woman have a complaint that is non-urgent? One of the example conditions listed was non-urgent symptoms may include: “Common discomforts of pregnancy, vaginal discharge, constipation, ligament pain, nausea, anxiety.” SCHEDULED/Priority 5 - Patients arriving for a pre-scheduled procedure or has no complaint. If the nurse notices that the woman has the need for a prescription refill, a scheduled outpatient procedure, or a scheduled procedure, she should answer “yes” to one of these two questions: 1. Is the woman requesting a service and she has no complaint? 2. Does the woman have a scheduled procedure with no complaint? One of the example conditions listed was: “Any event or procedure scheduled formally or informally with the unit before the patient’s arrival, when the patient has no complaint.” . The facility’s Assessment of the Emergency Department Patient policy, last reviewed and implemented on 08/04/2025, stated on page 1 of 3: “ ...1. All patients presenting to the Emergency Department will be triaged and categorized using the ESI 5-level triage system. (Gilboy, et al., 2020) 1. All patients admitted to the Emergency Department will have the following documentation: ... 2. Vital signs: ... b. Pain score ...” . The facility’s Leaving Against Medical Advice (AMA) policy, last reviewed and implemented on 02/05/2025, stated on page 1 of 3: “ ...2. Leaving Against Medical Advice Form: (outline of steps) 1. Notify the attending physician when a patient attempts or threatens to leave without receiving treatment or refuses treatment advised by the attending physician. 2. The attending physician and/or nurse will explain to the patient, parent, spouse or guardian refusing such treatment, possible untoward effects and/or injuries which can result. One of the Patient’s Rights is that of having the right to refuse treatment as permitted by law and regulations, and if the treatment is refused the patient will receive other needed and available care. Please also indicate that alternatives were discussed and/or offered to the patient. 3. After a patient, parent, spouse or guardian verbalizes understanding of all risks involved in refusing the advised treatment, the patient, parent spouse or guardian will sign a Leaving Against Medical Advice form. This form will be witnessed and signed by two hospital employees. 4. If the patient refuses to sign, it will be so noted on the Leaving Against Medical Advice form and on the patient’s chart. This form must still be witnessed and signed by two hospital employees ....” . And on page 2 of 3: “ ...3. DOCUMENTATION: 1. Chart in medical record all events that transpired and that attending physician was notified. Chart the explanations given to the patient regarding the possible untoward effects of refusing treatment. Include the signed and witnessed Leaving Against Medical Advice form with the patient’s permanent record. 2. If the patient refuses discharge planning, document this refusal in the medical record. 4. PATIENT LEAVING HOSPITAL WITHOUT NOTICE: 1. If the patient is discovered to be missing from the hospital room, security should be notified, and a hospital-wide search should be conducted. Code Search will be announced. 2. If the patient is deemed to be competent, and cannot be located, the physician should be notified and the patient should be dismissed. Chart in patient’s record all events that have transpired. ...” . MEDICAL RECORD REVIEWS: Patient #1 Medical Record Review for the ED visit: Patient #1, a 24-year-old female, was admitted to the Obstetrical Emergency Department (OBED) on 08/30/2025 at 9:18 AM Patient #1 was 12 weeks pregnant at the time of presentation. . At 9:32 AM, Staff #11 documented Patient #1’s chief complaints as “vaginal bleeding” and “abdominal cramping.” Using the MFTI algorithm per the Facilities “Triage of the Obersteric Woman in the OBED” policy, Staff #11 answered “yes” to “Does the woman have a complaint that is non-urgent?”, indicating a “Non-urgent/Priority 4”. The Facility’s medical record system altered thise score to be a “Urgent/Priority 2” based the Staff #11’s documented answers. Per the facility policy, the correct question requiring a appropriate “yes” response would include the “is this a high-risk situation?” - a category that explicitly includes active vaginal bleeding. A nursing pain assessment or nursing physical assessment were not located in the provided medical record. . Staff #2, the treating OB/GYN documented the chief complaint and history of present illness (HPI) beginning at 10:09 AM. The notes included: “ ...Review of Systems All other symptoms negative. Physical Exam: exam performed with chaperone present GEN: NAD [No abnormality detected] OB Exam: Cervical Exam: deferred FHTs [fetal heart tones]: unable to obtain by doppler ... ...Discussion with external provider was not performed. Follow up with [Staff #3, Patient #1’s primary OB/GYN who is also contracted by Facility A] for previously scheduled prenatal appt [appointment] on 9/8/2025. Instructed pelvic rest until then...” The notes were electronically signed by Staff #2 on 8/30/2025 at 10:15 AM. . Facility A’s Staff #11 did not follow the facility’s Assessment of the Emergency Department Patient policy when a pain score for Patient #1 was not documented nor was a nursing physical assessment documented in the medical record When vaginal bleeding and abdominal cramping was reported. . Record Review for Patient #15: Patient #15, a 63-year-old male, presented to the ED on 08/03/2025 at 10:47 PM via EMS with chief complaints of chest and back pain. A triage assessment was attempted beginning at 10:51 PM by ED RN, Staff #40. The chief complaint was documented by Staff #40 as, “Chest Pain (Patient brought in EMS for chest pain and back pain)”. . Nursing notes by the ED RN, Staff #39, included: “Pt yelling at staff. When pt asked to stop yelling he said “Fine I’m Leaving”. Pt LWBS [left without being seen], no paperwork signed.” The medical screening exam could not be obtained. There were no treatments initiated. The patient LWBS at 10:51 PM but did not sign the release form. There is no documentation by Staff #39 or Staff #40 stating the patient had been counseled on the risks of leaving before treatment or the benefits of staying for treatment. . The facility did not follow its Leaving Against Medical Advice (AMA) policy for Patient #15 who LWBS at 10:51 PM but did not sign the release form and no documentation of staff advising Patient #15 of the risks of leaving before treatment or the benefits of staying for treatment had been explained to the patient was documented by 2 hospital staff in the medical record. There was no documentation by nursing that the physician was notified of his intended departure. . Interviews: The Quality Director, Staff # 1, was interviewed throughout the investigation beginning on 10/14/2025 at 10:15 AM. Staff # 1 was asked if she saw documentation of a pain level on Patient #1. Staff #1 said no. . The ED Medical Director (Staff #14) was interviewed on 10/15/2025 at 10:58 AM. Staff #14 indicated [when referring to Patient #1’s medical record] that he would have done labs, a hemoglobin and Type and screen just in case “because of the bleeding” and would want to trend the hCG levels. Staff #14 further indicated that a standard panel (of labs and testing) for patients with vaginal bleeding is facility protocol. Staff #14 indicated that the protocol includes a CBC, CMP, T&S, and an ultrasound. . The Manager of Clinical Risk, Staff #5, was asked via email on 10/21/2025 at 4:52 PM about the hospital’s algorithm/protocol/policy for pregnant patients in the ED with vaginal bleeding notating the “Standard panel” of labs as mentioned by [Staff #14] in our interview. Staff #5 indicated that the facility did not have a algorithm/protocol/policy. The facility policy titled, Triage of the Obstetric Woman in the OBED, included a MIFTI algorithm for triaging pregnant women in the ED. . Patient #1’s primary OB/GYN, who is also contracted by Facility A, Staff #3, was interviewed on 10/22/2025 at 4:47 PM. Staff #3 indicated that American College of Obstetrics & Gynecologist (ACOG) guidelines were utilized by her in her practice and that she usually had conversations about whether the patient is comfortable at home with that knowledge verses being admitted for her comfort. .”

“STAFF TRAINING CFR(s): Applicable staff, as identified by the hospital, must be trained annually on the protocols and provisions implemented pursuant to this section. (i) The governing body must identify and document which staff must complete such training. (ii) the hospital must document in the staff personnel records that the training was successfully completed. (iii) the hospital must be able to demonstrate staff knowledge on the topics implemented pursuant to this section This Standard is not met as evidenced by: 45847 . Based on record review and interviews, the facility failed to ensure that emergency department staff were trained and competent in Emergency Medical Treatment and Labor (EMTALA) requirements as part of their emergency care responsibilities as required by 42 CFR 482.55(b)(3) when 2 of 6 staff members (Staff #2 and Staff #12) whose personnel records were reviewed did not have current or annual EMTALA training on record. The governing body did not identify and document which staff must complete such training in its Medical Staff Bylaws, Rules and Regulations or its Emergency Medical Treatment and Labor Act (EMTALA) policy, or in any other documents provided. . Document Reviews: A review of the following facility documents revealed no mention of which staff, by position or responsibilities, are required to have EMTALA training: . Medical Staffy Bylaws (last reviewed 04/26/2012 . Medical Staff Rules and Regulations (last reviewed 04/26/2012) . EMTALA Guidelines for Emergency Department Services (last reviewed 03/07/2025) . Department of Emergency Medicine Meeting Minutes (April - September 2025) . Quality Assurance and Improvement Plan and Program (QAPI last reviewed 11/14/2024) . Quality Council Meeting Minutes (February - September 2025). . The facility’s “Compliance Communication & Education Plan” was provided on 10/23/2025 at 3:32 PM, which did not include a reviewed or implemented dates by the Governing Body, which indicated page 2 of 2 that all employees and the hospital med staff receive EMTALA education upon hire; and the ED, W&C [Women’s and Children’s], Patient Access, and HIM [Health Information Management] receive education annually. Medical staff receive education upon appointment. . The OB/GYN who was on call to provide emergency services in the OBED on 08/30/2025 during Patient #1’s ED visit was not provided with EMTALA training. . Interviews: The Quality Director, Staff # 1, was interviewed throughout the investigation beginning on 10/14/2025 at 10:15 AM. Staff #1 stated the OBED staff are not required to receive EMTALA training. Staff #1 stated the hospitalists in the OBED receive EMTALA training. . Staff #1 was asked why Staff #2 was covering the on-call hospitalist position for the OBED. Staff #1 indicated that their OB/GYN’s sometimes cover a hospitalist in the OBED as needed to complete the on-call schedule. Additionally, Staff #1 was asked how they ensure OB/GYN covering emergency services are compliant with EMTALA if they do not receive training. Staff #1 indicated that they have never had an issue with it. . Staff #43, Medical Staff Specialist, was interviewed during the medical staff personnel record reviews on 10/14/2025 at approximately 3:00 PM. Staff #43 was asked if the OB/GYN physicians were required to have EMTALA training. Staff #43 said no. . The Manager of Clinical Risk, Staff #5, was asked via email on 10/22/2025 at 3:30 PM, “Do you have a policy or protocol approved by your governing body related to who gets/does not get EMTALA training? If you do, please forward a copy. Staff #5 replied via email on 10/23/2025 at 3:32 PM, “All employees and [the hospital’s] med staff receive EMTALA education upon hire, the ED, W&C [Women and Children], Patient Access, and HIM [Health Information Management] receive education annually. Medical staff receive education upon appointment.” .”

“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: 51905 . Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. . Based on observation, record review, and interviews, Facility A failed to perform an appropriate transfer for one of twenty patients (Patient #12) when the physician certification, outlining the risks and benefits and the physician’s signature for the patient to safely transfer, was not documented by a physician. . See Tag 2409 .”

“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: 51905 . Based on observation, record review, and interviews, Facility A failed to perform an appropriate transfer for one of twenty patients (Patient #12) when the physician certification, outlining the risks and benefits and the physician’s signature for the patient to safely transfer, was not documented by a physician. . Review of Patient #12’s medical record from Facility A: . 05/29/2025 at 6:44 A.M., Patient #12 presented to Facility A’s emergency department with a chief complaint of suicidal ideation. The physician notes that Patient #12 had a history of schizophrenia and visual hallucinations. A documented assessment indicated that Patient #12 had plans to do harm by choking themself or throwing themself off a bridge to end their life. Patient #12’s medical screening exam was within normal limits. At 6:52 A.M., a positive suicide risk screening was completed by a registered nurse. At 8:30 A.M., a mental health assessor assessed Patient #12 and recommended an emergency detainment order and transfer to a behavioral health facility. At 12:07 P.M., Patient #12 was administered Ativan. At 12:25 P.M., the memorandum of transfer was partially completed. The physician certification was left blank. The risks and benefits were not documented, and the physician did not sign off on the transfer. At 12:37 P.M., Patient #12 was transferred to a behavioral health facility. . Review of EMTALA (Emergency Medical Treatment and Labor Act) Guidelines for Emergency Department Services Policy Effective 03/07/2025: . Page 1 of 13 “Definitions Physician Certification refers to written certification by the treating physician ordering the transfer prior to the patient’s transfer that, based on 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 and, in the case of a woman in labor, to the unborn child from effecting the transfer. The certification shall include a summary of the risks and benefits upon which the certification is based and the reason(s) for the transfer. If a physician is not physically present at the time of transfer, a QMP can sign the certification as long as the QMP is in consultation with the physician and the physician is in agreement with the certification and subsequently, countersigns the certification. The date and time of such certification should closely match the date and time of the transfer.” . Page 11 of 13 “Transfer Obligations: United Regional may transfer an individual with an EMC that has not been stabilized if the transfer is appropriate; and if A physician certifies in writing that based on the information available at the time, 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 unborn child, from being transferred. A summary of the risks and benefits upon which the decision is based must be included; or” . Interview with Emergency Department Quality and Education, Staff B on 08/04/2025 at 10:29 A.M. . Staff B reviewed Patient #12’s medical record and memorandum of transfer with the surveyor. Staff B was asked if the form was completed. Staff B indicated no; the form was not completed. Staff B was asked if there was another place where a completed form may be found. Staff B indicated no; the forms are scanned into the medical record. .”