Weston County Health Services

“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: 53839 16146 Based on medical record review, patient, family and staff interviews, and review of policies and procedures and the emergency department (ED) log, the facility failed to ensure an appropriate medical screening examination was completed for 1 of 20 sample patients (#6) who presented to the ED and failed to provide stabilizing treatment for an emergency medical condition for 1 of 20 sample patients (#6). In addition, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 3 of 3 patients (#3, #5, #14) who had an emergency medical condition and were transferred to another facility. The findings were: 1. Refer to C-2406 for details on the facility’s failure to provide an adequate medical screening examination for patient #6. 2. Refer to C-2407 for details on the facility’s failure to provide stabilizing treatment for patient #6, who had a psychiatric emergency medical condition. 3. Refer to C-2409 for details on the facility’s failure to ensure a physician signed the transfer certification for patients #3, #5, and #14.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or 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 traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) 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 (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 53839 16146 Based on observation, staff interview and review of policies and procedures, the facility failed to post conspicuously in the emergency department (ED) a sign that specified the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor and failed to post information whether or not the facility participates in the Medicaid program. The findings were: 1. Observation of the ED on 2/19/26 at 1:52 PM to include the entrance, waiting areas, hallways, treatment rooms and ambulance bay showed no signs posted that specified the rights of individuals related to EMTALA. In addition, there lacked any posted information to indicate if the facility participated in the Medicaid program. RN #1 confirmed the lack of signs at the time of the observation. 2. Review of the facility policy “EMTALA,” reviewed 1/2026, showed “...A. EMTALA signs. The Hospital will post conspicuously signs explaining individuals’ EMTALA rights in the Emergency Department, Labor and Delivery Department, and other areas where individuals are likely to wait for examination or treatment. B. Medicaid signs. The Hospital will post conspicuously information indicating whether the Hospital participates in Medicaid.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 53839 16146 Based on medical record review, staff, patient and family interviews, and review of policies and procedures and the emergency department (ED) log, the facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 20 sample patients (#6). The findings were: 1. Review of the ED log showed patient #6 presented to the ED on 11/16/25 at 2:55 PM by ambulance. Review of the ambulance report for 11/16/25 showed the ambulance was dispatched for a reported overdose. The report showed the patient was being restrained by police due to suicidal ideation. The patient reportedly took multiple benzodiazepines (class of medications that slow down activity in brain and nervous system) and “other downer agents” that are not know to EMS (emergency medical services). Law enforcement informed EMS they were placing the patient on a Title 25 hold (involuntary hold) due to the patient being a harm to himself/herself and others and possible suicidal actions. The patient was less than cooperative, refused to answer questions and alcohol odor was present. Review of the police report for 11/16/25 showed the patient “had made a comment something to the effect of being a [woman/man] who wanted to die.” The officer spoke with the patient who learned s/he possibly took 60 Valium (benzodiazepine). The police summoned EMS. Review of an ED note on 11/16/25 by registered nurse (RN) #1 showed the patient arrived at 2:55 PM with EMS and law enforcement for alcohol intoxication. The patient was uncooperative and yelling profanities at staff and officers. The nurse was unable to obtain vital signs or get verbal cooperation from the patient. The officer requested Title 25 paperwork and the paperwork was provided. A note at 2:56 PM by RN #1 showed EMS reported the patient possibly ingested approximately 61 tablets of Valium 5 milligrams (mg), 2 tablets of Seroquel (antipsychotic) 25 mg, and 3 tablets of hydralazine (treat high blood pressure) 25 mg at an unknown time. Review of the ED provider note by nurse practitioner (NP) #1 dated 11/16/25 showed the patient was noted to be intoxicated at church. The patient then went home and stated “took a bunch of stuff.” On arrival the patient was combative and uncooperative. The patient told friends of his/her mother that s/he took a lot of stuff and when law enforcement arrived s/he said s/he wanted to kill himself/herself. Patient then said s/he didn’t want to kill himself/herself. The patient was clearly intoxicated and very verbally and physically aggressive. The officers placed the patient under a Title 25 hold and were seeking evaluation of the patient’s condition. Further review of the provider note showed the blood alcohol level was 343 (80 mg/dL is legally intoxicated). The urine drug screen was positive for benzodiazepines. The provider’s examination for “psychiatric” showed “Mood and Affect: Affect is angry and inappropriate. Speech: Speech is rapid and pressured. Behavior: Behavior is agitated. Judgement: Judgement is inappropriate.” The provider’s note further showed the patient told law enforcement “I’m just a [man/lady] that wants to kill [himself/herself].” The patient denied that statement on questioning in the ED. The provider documented she contacted some behavioral health agencies. The following concerns were identified: a. Review of a progress note by RN #1 on 11/16/25 at 4:20 PM showed she called mental health agency #1 and they stated they were unable to evaluate the patient because the patient was intoxicated. The agency informed the nurse that police officers were not able to place a patient on a Title 25 hold because they were not a mental health evaluator; only the provider could do that. The nurse informed NP #1. b. Review of the provider’s note showed mental health agency #1 stated they were unable to interview the patient while intoxicated. The provider documented that she contacted administration (acute care director of nursing) for a recommendation because the patient was medically cleared and law enforcement was not able to arrest the patient. The provider stated they would discharge the patient. The provider noted she offered to admit the patient with law enforcement in attendance, but law enforcement requested discharge. c. The provider documented at 5:30 PM she received a call from the patient’s mother who told her the patient was suicidal and had been for years. The provider stated the patient denied thoughts of suicidal ideations. The provider called the mother back and stated there was no medical reason to hold the patient, that law enforcement could not arrest him/her and that the mental health agency could not assess the patient while intoxicated. The provider informed the mother that the patient was uncooperative and verbally abusive to staff and law enforcement. While the provider was dealing with the police and the patient’s mother, the patient pulled out his/her IV and got dressed and walked out of the ED with several rude comments to the police and staff. Since the patient had been verbally and physically aggressive, staff did not attempt to stop him/her. d. There lacked evidence of a mental health evaluation or a thorough psychiatric history and examination by the provider in order to determine if there was an emergency medical condition. e. During an interview on 2/19/26 at 10:46 AM the patient’s mother stated the patient tried to commit suicide and took a bunch of pills. She stated her friends were with her daughter/son and they let her know what was going on. She stated she called the ED provider and asked her not to discharge the patient because s/he was suicidal. The mother stated the patient told everybody s/he had taken 61 pills of “librium” (benzodiazepine). The mother stated as far as she knew, the ED staff never asked the patient if s/he took anything. She stated the patient had a history of mental illness, intoxication, and previous suicide attempts. f. On 2/19/26 at 11:34 AM NP #1 stated the patient was intoxicated at church earlier that day and friends were concerned about him/her when they went to their house after church. The NP stated since she was not there she could not say exactly what EMS was told, but friends were concerned about him/her. She stated EMS brought some pill bottles, but they were unsure if the patient took them or not. The provider stated the patient was verbally abusive. She stated laboratory results showed the patient was intoxicated and the urine test was positive for benzodiazepines, but that the patient was prescribed Valium twice per day. She stated the patient denied suicidal ideations to her. She stated she offered to Title 25 the patient and keep him/her, but that police would have to stay with the patient. The police declined to do that. When asked why the police would need to stay with the patient she stated their staffing ratio did not allow for a 1:1 sitter. The provider stated she was not able to evaluate and Title 25 a patient because she was not a licensed mental health provider. She stated she evaluated the patient for “medical clearance.” She stated mental health agency #1 was not able to evaluate the patient while the patient was intoxicated. g. During an interview on 2/19/26 at 1:45 PM RN #1 stated the patient was brought in by EMS due to intoxication and the patient had screamed s/he was suicidal. She stated the Columbia suicide risk assessment was normally done, but was not on this patient because the patient was uncooperative. The RN further stated if a Title 25 patient was uncooperative, then the police would be asked to stay. She stated if a 1:1 sitter was needed, then nurses could be called in until they were able to transfer the patient to a facility with mental health services. h. On 2/19/26 at 2:10 PM patient #6 stated s/he was upset with the ED staff’s lack of handling his/her “mental crisis.” The patient stated s/he had taken 61 pills of “librium.” She stated s/he told EMS and the police that s/he was “better off dead.” S/he stated the ED did not do anything; s/he had no mental health evaluation. i. During an interview on 2/19/26 at 2:53 PM the acute care director of nursing (DON) stated it was not facility policy to have police remain with a patient who was on a Title 25, but that they asked an officer to stay if the patient was a threat to staff. She stated she didn’t think the provider felt patient #6 needed to be placed on Title 25. She stated if a patient needed 1:1, then other nurses or aides could be called in, or they could use e-emergency (electronic visual monitoring service). 2. Review of the facility’s policy “EMTALA,” reviewed 1/2026, showed “...1. Medical Screening Examination. If a person comes to the Hospital and a request is made for their emergency care or, if the person is unable to communicate, a reasonable person would believe that the person is in need of emergency care, then qualified medical personnel will, within the Hospital’s capability and capacity, conduct and document an appropriate medical screening examination reasonably calculated to identify an emergency medical condition. An appropriate medical screening examination should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms, including but not limited to a history of the presenting problem; a documented physical examination of the involved area or system; and the use of on-call physicians and ancillary tests or services routinely available to the Hospital if needed to determine whether an emergency medical condition exists...Emergency medical condition is a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (1) placing the health of the individual (including the health of an unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part...” 3. Review of the facility’s policy “Emergency Detention, 161.300,” revised 09/2025, showed “When a law enforcement officer or examiner has reasonable cause to believe a person is mentally ill pursuant to W.S. 25-10-101, and that person is brought to the emergency department The person will have an appropriate medical screening exam and can also be evaluated by a mental health provider. The ED provider and/or the mental health provider can determine if Title 25 is appropriate.””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 53839 16146 Based on medical record review, staff, patient and family interviews, and review of policies and procedures and the emergency department (ED) log, the facility failed to provide stabilizing treatment for an emergency medical condition, or transfer the patient to another medical facility, for 1 of 20 sample patients (#6). The findings were: 1. Review of the ED log showed patient #6 presented to the ED on 11/16/25 at 2:55 PM by ambulance. Review of the ambulance report for 11/16/25 showed the ambulance was dispatched for a reported overdose. The report showed the patient was being restrained by police due to suicidal ideation. The patient reportedly took multiple benzodiazepines (class of medications that slow down activity in brain and nervous system) and “other downer agents” that are not know to EMS (emergency medical services). Law enforcement informed EMS they were placing the patient on a Title 25 hold (involuntary hold) due to the patient being a harm to himself/herself and others and possible suicidal actions. The patient was less than cooperative, refused to answer questions and alcohol odor was present. Review of the police report for 11/16/25 showed the patient “had made a comment something to the effect of being a [woman/man] who wanted to die.” The officer spoke with the patient who learned s/he possibly took 60 Valium (benzodiazepine). The police summoned EMS. Review of an ED note on 11/16/25 by registered nurse (RN) #1 showed the patient arrived at 2:55 PM with EMS and law enforcement for alcohol intoxication. The patient was uncooperative and yelling profanities at staff and officers. The nurse was unable to obtain vital signs or get verbal cooperation from the patient. The officer requested Title 25 paperwork and the paperwork was provided. A note at 2:56 PM by RN #1 showed EMS reported the patient possibly ingested approximately 61 tablets of Valium 5 milligrams (mg), 2 tablets of Seroquel (antipsychotic) 25 mg, and 3 tablets of hydralazine (treat high blood pressure) 25 mg at an unknown time. Review of the ED provider note by nurse practitioner (NP) #1 dated 11/16/25 showed the patient was noted to be intoxicated at church. The patient then went home and stated “took a bunch of stuff.” On arrival the patient was combative and uncooperative. The patient told friends of his/her mother that s/he took a lot of stuff and when law enforcement arrived s/he said s/he wanted to kill himself/herself. Patient then said s/he didn’t want to kill himself/herself. The patient was clearly intoxicated and very verbally and physically aggressive. The officers placed the patient under a Title 25 hold and were seeking evaluation of the patient’s condition. Further review of the provider note showed the blood alcohol level was 343 (80 mg/dL is legally intoxicated). The urine drug screen was positive for benzodiazepines. The provider’s examination for “psychiatric” showed “Mood and Affect: Affect is angry and inappropriate. Speech: Speech is rapid and pressured. Behavior: Behavior is agitated. Judgement: Judgement is inappropriate.” The provider’s note further showed the patient told law enforcement “I’m just a [man/lady] that wants to kill [himself/herself].” The patient denied that statement on questioning in the ED. The provider documented she contacted some behavioral health agencies. The following concerns were identified: a. Review of a progress note by RN #1 on 11/16/25 at 4:20 PM showed she called mental health agency #1 and they stated they were unable to evaluate the patient because the patient was intoxicated. The agency informed the nurse that police officers were not able to place a patient on a Title 25 hold because they were not a mental health evaluator; only the provider could do that. The nurse informed NP #1. b. Review of the provider’s note showed mental health agency #1 stated they were unable to interview the patient while intoxicated. The provider documented that she contacted administration (acute care director of nursing) for a recommendation because the patient was medically cleared and law enforcement was not able to arrest the patient. The provider stated they would discharge the patient. The provider noted she offered to admit the patient with law enforcement in attendance, but law enforcement requested discharge. c. The provider documented at 5:30 PM she received a call from the patient’s mother who told her the patient was suicidal and had been for years. The provider stated the patient denied thoughts of suicidal ideations. The provider called the mother back and stated there was no medical reason to hold the patient, that law enforcement could not arrest him/her and that the mental health agency could not assess the patient while intoxicated. The provider informed the mother that the patient was uncooperative and verbally abusive to staff and law enforcement. While the provider was dealing with the police and the patient’s mother, the patient pulled out his/her IV and got dressed and walked out of the ED with several rude comments to the police and staff. Since the patient had been verbally and physically aggressive, staff did not attempt to stop him/her. d. Review of the medical record showed no evidence the patient was placed on a hold, nor evidence of continuous observation (such as a 1:1 sitter) or a suicide safe environment. e. During an interview on 2/19/26 at 10:46 AM the patient’s mother stated the patient tried to commit suicide and took a bunch of pills. She stated her friends were with her daughter/son and they let her know what was going on. She stated she called the ED provider and asked her not to discharge the patient because s/he was suicidal. The mother stated the patient told everybody s/he had taken 61 pills of “librium” (benzodiazepine). She stated the patient had a history of mental illness, intoxication, and previous suicide attempts. f. On 2/19/26 at 11:34 AM NP #1 stated the patient was intoxicated at church earlier that day and friends were concerned about him/her when they went to their house after church. The NP stated since she was not there she could not say exactly what EMS was told, but friends were concerned about him/her. She stated EMS brought some pill bottles, but they were unsure if the patient took them or not. The provider stated the patient was verbally abusive. She stated laboratory results showed the patient was intoxicated and the urine test was positive for benzodiazepines, but that the patient was prescribed Valium twice per day. She stated the patient denied suicidal ideations to her. She stated she offered to Title 25 the patient and keep him/her, but that police would have to stay with the patient. The police declined to do that. When asked why the police would need to stay with the patient she stated their staffing ratio did not allow for a 1:1 sitter. The provider stated she was not able to evaluate and Title 25 a patient because she was not a licensed mental health provider. She stated she evaluated the patient for “medical clearance.” She stated mental health agency #1 was not able to evaluate the patient while the patient was intoxicated. g. During an interview on 2/19/26 at 1:45 PM RN #1 stated the patient was brought in by EMS due to intoxication and the patient had screamed s/he was suicidal. She stated the Columbia suicide risk assessment was normally done, but was not on this patient because the patient was uncooperative. The RN further stated if a Title 25 patient was uncooperative, then the police would be asked to stay. She stated if a 1:1 sitter was needed, then nurses could be called in until they were able to transfer the patient to a facility with mental health services. h. On 2/19/26 at 2:10 PM patient #6 stated s/he was upset with the ED staff’s lack of handling his/her “mental crisis.” The patient stated s/he had taken 61 pills of “librium.” She stated s/he told EMS and the police that s/he was “better off dead.” S/he stated the ED did not do anything; s/he had no mental health evaluation. i. During an interview on 2/19/26 at 2:53 PM the acute care director of nursing (DON) stated it was not facility policy to have police remain with a patient who was on a Title 25, but that they asked an officer to stay if the patient was a threat to staff. She stated she didn’t think the provider felt patient #6 needed to be placed on Title 25. She stated if a patient needed 1:1, then other nurses or aides could be called in, or they could use e-emergency (electronic visual monitoring service). 2. Review of the facility’s policy “EMTALA,” reviewed 1/2026, showed “...Emergency medical condition is a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (1) placing the health of the individual (including the health of an unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part...If the medical screening examination indicates that the person has an emergency medical condition, the Hospital will provide : (1) treatment within the capabilities of the staff and facilities routinely available at the Hospital (including on-call physicians and ancillary services routinely available) as required to stabilize the person before the person is discharged or transferred to another facility; or (2) an appropriate discharge or transfer as described below. 3. Appropriate Discharge or Transfer. A. Stabilized person...A person is deemed stabilized under the following circumstances: ...4. For psychiatric conditions: if the person is not in danger of harming themselves or others, or they are protected from harming themselves or others.” 3. Review of the facility’s policy “Emergency Detention, 161.300,” revised 09/2025, showed “When a law enforcement officer or examiner has reasonable cause to believe a person is mentally ill pursuant to W.S. 25-10-101, and that person is brought to the emergency department. The person will have an appropriate medical screening exam and can also be evaluated by a mental health provider. The ED provider and/or the mental health provider can determine if Title 25 is appropriate.””

“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: 53839 Based on medical record review, staff interviews and review of policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 3 of 3 patients (#3, #5, #14) who had an emergency medical condition and were transferred to another facility. The findings were: 1. Review of the medical record showed patient #3 presented to the ED on 11/14/25 for a possible pregnancy problem. The patient stated she thought she was 32 weeks pregnant. The notes by physician assistant (PA) #1 showed the patient had clear watery vaginal discharge and the cervix was dilated 6 centimeters (cm), 4 cm deep to “os” (cervical opening). The fetal heart rate was monitored and was 130-160 beats per minute and no contractions were noted on the monitor. The PA contacted an obstetrician at hospital B who agreed to the transfer for anticipated delivery. The patient and the baby’s father declined EMS and decided to travel by personal vehicle. The risks were explained by the PA and they signed the private vehicle transportation transfer form. The following concerns were identified: a. Review of the transfer certification showed it was signed by PA #1. There was no countersignature from a physician. b. During an interview on 2/19/26 at 11:02 AM PA #1 stated she signed the transfer certifications but was unsure of the policies related to countersignatures. She stated all transfers were reviewed by the medical director, but she was unsure if transfer certifications were signed by a physician. 2. Review of the medical record showed patient #5 presented to the ED on 1/12/26 for vaginal bleeding at 25 weeks pregnant. Nurse practitioner (NP) #2 spoke to the obstetrician at hospital A who agreed to accept the patient as a transfer for OB monitoring and treatment. The patient was transferred via ambulance. The following concerns were identified: a. Review of the transfer certification showed it was signed by NP #2. There was no countersignature from a physician. b. During an interview on 2/19/26 at 10:30 AM NP #2 stated he completed and signed the certifications for transfers. He stated he believed all transfers were reviewed in a monthly meeting by the medical director, but was unsure of any other procedures related to transfer certifications. 3. Review of the medical record indicated patient #14 arrived on 12/12/25 at 09:29 AM for right flank pain for two days. Based on the medical screening evaluation a CT (computed tomography) scan identified an 8-millimeter (mm) obstructing stone in the proximal right ureter causing severe hydronephrosis (kidney swelling due to buildup of urine that cannot drain from the kidney to the bladder often as a result of blockage or obstruction) and 2 mm non-obstructing stone in the lower pole of the left kidney. A urology consult with an outside facility was obtained and it was determined that a transfer was necessary. The following concerns were identified: a. Further review of the medical record showed that the mid-level practitioner signed the EMTALA transfer certificate. The transfer certificate was not countersigned by a physician. b. Interview with physician assistant (PA) #1 on 2/19/26 at 11:03 AM revealed she knew all transfers were reviewed by the physician, but she was unaware if they get signed. 4. Interview with physician #1 on 2/18/26 at 4:29 PM revealed he was the only physician in the emergency department and he has never countersigned an EMTALA transfer certificate, and was unaware it was required. 5. Review of the facility’s policy “EMTALA” last reviewed 01/2026 showed “... (2) a provider certifies in writing that the benefits of discharge or transfer outweigh the risks” ...” if a provider is not physically present, a qualified medical person consults with a provider and certifies in writing that the benefits of discharge or transfer outweigh the risks. The provider must subsequently countersign the certification” The policy did not define “provider.” 16146”