HospitalInspections.org

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.

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.

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.