Adventist Health St Helena

“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: 50121 Based on staff interview, hospital document review, and policy and procedure (P&P) review the facility failed, for one of 20 (Patient 1) sampled patients, to 1. Provide treatment within their capabilities, and (See A 2407) 2. Review risks of refusing transfer with Patient 1 and instead discharged Patient 1 with instructions to present at a trauma center. (See A 2708) These failures resulted in the delay of treatment of Patient 1’s severe eye injury which had the potential to cause Patient 1 severe eye infections, further damage or loss of the eye structure, and blindness. The cumulative effect of these failures resulted in the hospital’s inability to meet Emergency Medical Treatment and Labor Act (EMTALA) requirements.”

“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: 41175 Based on interview and record review, the facility failed to provide treatment within their capabilities to one of 20 sampled patients (Patient 1) who presented to the Emergency Department (ED) with a globe rupture (an eyeball injury involving a full-thickness tear in the eye wall that causes the eye contents to extrude outside the eye), when there was no evidence of stabilizing treatment and documentation that risks of declining further stabilization and appropriate transfer were discussed with Patient 1 prior to him leaving the ED. This failure resulted in the delay of treatment of Patient 1’s emergency medical condition of a globe rupture, which may lead to complications such as severe eye infections, further damage or loss of the eye structure, and blindness. Findings: During a review of Patient 1’s “ED Depart Summary”, dated 11/28/25, the Summary indicated Patient 1 arrived at the ED at 11:49 a.m. with an eye injury after a mirror fell on his face. Patient 1 was triaged as “Acuity Level 2-Very Urgent” (patient is unstable or presents with a condition that pose an acute threat to life, limb or bodily function requiring rapid or emergency intervention). According to the Summary, at 11:53 a.m., Patient 1 was placed on an ED bed and seen by an ED provider for a medical screening exam. Ten minutes later, at 12:03 p.m., the Summary indicated Patient 1 was discharged from the ED. Further review of Patient 1’s ED Depart Summary indicated, “Discharge Disposition: Home or Self Care ... Patient Education: Eye Contusion ... Follow-Up Comment: Go now to a trauma center.” During a review of Patient 1’s “ED Physician Notes” dated 11/28/25, the Notes indicated, “Patient has obvious trauma to the face. There is a laceration below the right eye over the right cheek. There is no active bleeding. His right eye is completely shut. I opened up the eyelids that were swollen shut to do an evaluation of the eye and globe of the right eye. Upon opening the eyelids there is obvious vitreous [gel-like contents of the eye] material coming out of the eye. The pupil appears dislodged and there is clear vitreous material coming out of the right eye.” The Notes indicated Patient 1 was diagnosed with a right eye trauma with globe rupture. During an interview on 1/21/25 at 9:57 a.m., Nurse B stated she recalled triaging Patient 1 in the ED on 11/28/25. Nurse B stated Patient 1 came in with a closed eye and did not want her to open it as it was too swollen and painful. Nurse B stated she left Patient 1’s room to give Physician A report on Patient 1’s condition, who then entered into the room. Nurse B stated Physician A came out a few minutes later and told her Patient 1 needed to be transferred because he had a globe rupture, and the facility did not have ophthalmology (medical specialty in eye diseases and disorders) services. During an interview on 1/21/25 at 10:29 am., Nurse C stated she was Patient 1’s primary nurse on 11/28/25 after he was triaged. Nurse C stated after Physician A came out of Patient 1’s room, she was instructed to apply an eye patch on Patient 1 and clean the area around his eye. Nurse C stated Physician A told her Patient 1 needed to be transferred, but Patient 1 wanted to leave, because he, “didn’t want to wait for the ambulance “. Nurse C stated Patient 1 did not sign a declination of a transfer, nor was he provided one. Nurse C stated she asked Physician A if he wanted Patient 1 to sign one, but Physician A told her he wanted Patient 1 “to be discharged because he would be going to a trauma center”. During an interview on 1/22/25 at 12:11 p.m., Physician A stated after his physical assessment of Patient 1’s eye, it was an obvious, “slam dunk diagnosis” of a globe rupture. Physician A stated he saw the immediate need for a trauma center for ophthalmology services which the facility did not have. Physician A stated there were other interventions within the hospital capabilities that he would have ordered, “had Patient 1 not been in a hurry to leave”, such as blood work, antibiotics, intravenous fluids, CT (computed tomography) scan imaging, and procaine (a type of pain medication). When asked if the above-mentioned treatment options were offered and explained to Patient 1 before he left, Physician A stated, “there was not much he could do,” because as soon as Patient 1 heard the words “need for transfer”, he immediately wanted to leave. During a review of Patient 1’s “[Hospital 2] ED Provider Notes”, dated 11/28/25 and timestamped 1417 (2:17 p.m.), the Note indicated Patient 1 underwent CT imaging of the head without contrast (intravenous or oral agents used to enhance x-ray images), CT imaging of the head and neck with contrast, and blood tests. Patient 1 received oxygen therapy, pain medications, and intravenous fluids. Further review of the Note indicated Patient 1 was both evaluated by a trauma surgeon and an ophthalmologist, who confirmed he sustained a full thickness conral (sic) laceration of the right eye. The Note further indicated Patient 1 needed a transfer to a tertiary center (a major, highly specialized hospital that provides advanced medical interventions, complex treatment, and surgical procedures for severe or rare conditions), and at 1723 (5:23 p.m.), Hospital 3 accepted Patient 1’s transfer. During a review of the facility policy and procedure (P&P) titled, “MODEL POLICY: EMTALA - PATIENT LWBS [Left Without Being Seen], ELOPEMENT, AMA [Against Medical Advice], LABS [Left After Being Seen]” dated 6/6/19, the P&P indicated, “All patients leaving the Emergency Department ... will be offered the Medical Screening Examination and encouraged to remain in the Department to receive Emergency Services and Care ... All patients who refuse further examination and Stabilizing treatment after receiving a Medical Screening Examination will be informed of the obligations of the Hospital to provide Emergency Services and Care, the benefits of further examination or treatment, the risks of leaving, and any alternatives, and requested to sign an AMA form ... Dedicated Emergency Department staff will take reasonable steps to obtain a written refusal from the patient (or his/her representative) who is leaving the Hospital against medical advice. i. The AMA form will be completed to document the patient’s refusal. ii. The patient ... will be given a copy of the form. iii. If the patient ... refuses or leaves before the form can be signed, the reason for the lack of written refusal will be written on the form and the patient’s written medical record by the Treating Physician or the registered nurse assigned to the patient ...””

“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: 41175 Based on interview and record review, the facility failed to obtain a written informed transfer refusal of one of 20 sampled patients (Patient 1) who presented to the Emergency Department (ED) with a globe rupture (an eyeball injury involving a full-thickness tear in the eye wall that causes the eye contents to extrude outside the eye), when there was no explicit documentation that Patient 1 was educated of the risks and benefits of leaving without an appropriate hospital transfer. This failure resulted in Patient 1 to be driven by his significant other to another emergency department via private vehicle. Sudden movements and accidental pressure on the eye during transport or an improperly stabilized head increased the potential for his emergency condition to develop complications such as severe eye infections, further damage or loss of the eye structure, and blindness. Findings: During a review of Patient 1’s “ED Depart Summary”, dated 11/28/25, the Summary indicated Patient 1 arrived at the ED at 11:49 a.m. with an eye injury, after a mirror fell on his face. Patient 1 was triaged as “Acuity Level 2-Very Urgent” (conditions that pose an acute threat to life, limb or bodily function requiring rapid or emergency intervention; patient is unstable). According to the Summary, at 11:53 a.m., Patient 1 was placed on an ED bed and seen by an ED provider. 10 minutes later, at 12:03 p.m., the Summary indicated Patient 1 was discharged from the ED. During a review of Patient 1’s “ED Physician Notes” dated 11/28/25, the Notes indicated, “Patient has obvious trauma to the face. There is a laceration below the right eye over the right cheek. There is no active bleeding. His right eye is completely shut. I opened up the eyelids that were swollen shut to do an evaluation of the eye and globe of the right eye. Upon opening the eyelids there is obvious vitreous (gel-like contents of the eye) material coming out of the eye. The pupil appears dislodged and there is clear vitreous material coming out of the right eye.” Further review of the Notes indicated, “Medical Decision Making:...we will need to transfer him to a likely a trauma facility or at a minimum a facility that has a (sic) ophthalmologist ... they just want to leave and drive over to [Hospital 2]...I explained I think that is reasonable option at this point in time. It would take some time for me to coordinate transfer and get a (sic) ambulance ...” Patient 1’s ED Physician Notes indicated he was diagnosed with a right eye trauma with globe rupture of the right eye. Patient 1’s ED Physician Notes indicated he was discharged to home and provided with the patient education for “Eye Contusion” with a follow-up comment to “Go now to a trauma center.” During an interview on 1/21/25 at 10:29 am., Nurse C stated she was Patient 1’s primary nurse on 11/28/25 after he was triaged. Nurse C stated after Physician A came out of Patient 1’s room, she was instructed to apply an eye patch on Patient 1 and clean the area around his eye. Nurse C stated Physician A told her Patient 1 needed to be transferred, but Patient 1 wanted to leave because he “didn’t want to wait for the ambulance”. Nurse C stated Patient 1 did not sign a declination of transfer, nor was he provided one. Nurse C stated she asked Physician A if he wanted Patient 1 to sign one, but Physician A told her he “wanted Patient 1 to be discharged because he would be going to a trauma center”. During a concurrent interview and record review on 1/21/25 at 10:45 a.m. with ED Director, Patient 1’s “ED Physician Notes” dated 11/28/25 were reviewed. ED Director stated Patient 1 needed to be transferred and confirmed there was no signed declination of a transfer. ED Director stated she expected that risks, benefits and all the required elements of the EMTALA regulations, should be clearly explained to patients and detailed in the documentation when a patient refused care or transfers. During a concurrent interview and record review on 1/22/25 at 10:20 a.m. with Physician A, Patient 1’s “ED Physician Notes”, dated 11/28/25 were reviewed. Physician A stated in the event of a patient refusal of care or declination of transfer, he approached it with a straightforward conversation with the patient and giving as much information including the risks, benefits, and alternatives. Physician A stated he would document the refusal, what was discussed, and that all questions were answered. Physician A stated during Patient 1’s ED visit on 11/28/25, he explained to Patient 1 the need to transfer to a trauma center because the facility did not have ophthalmology services. Physician A stated after he explained the transfer process, Patient 1 and his significant other wanted to leave immediately. Physician A stated he explained to Patient 1 that declining a transfer meant he could not offer further help such as talking to other physicians. Physician A stated he felt very clear Patient 1 was aware of everything that was going on, understood the risks, and that he and his significant other were taking it into their hands to get to the next facility. Physician A confirmed the ED Physician Notes did not explicitly state that he had explained the risks and benefits of declining the transfer with Patient 1 and added he had to do better at documenting what was discussed. During a review of Patient 1’s “[Hospital 2] ED Provider Notes”, dated 11/28/25 and timestamped 1417 (2:17 p.m.), the Notes indicated Patient 1 was evaluated by a trauma surgeon and an ophthalmologist, who confirmed Patient 1 had sustained a full thickness conral (sic) laceration of the right eye. The Notes further indicated Patient 1 needed a transfer to a tertiary center (a major, highly specialized healthcare facility that provides advanced medical investigation, complex treatment, and surgical procedures for severe or rare conditions), and at 1723 (5:23 p.m.), Hospital 3 accepted the transfer. During a review of an undated facility policy and procedure (P&P) titled, “STANDARD POLICY: EMTALA - PATIENT TRANSFER”, the P&P indicated, “If an individual, whether he/she has an Emergency Medical Condition that is Stabilized or not Stabilized, is notified by the Hospital of a proposed Transfer, and the individual (or his/her legal representative) refuses to accept the Transfer, the Hospital will continue to provide further examination and Stabilizing treatment within its Capability to the Individual. The Hospital will take the following steps to secure a written refusal to accept the Transfer: 1. The Treating Physician will explain to the individual ... the (i) the reasons for the Transfer; (ii) the benefits of the Transfer to the individual ...; (iii) the risks reasonably expected from the Transfer or refusing the Transfer to the individual ... 2. The Treating Physician will enter in the medical record that the individual ... has been advised of the reasons, benefits and risks or the Transfer, and the Individual ... refuses the Transfer. 3. The Hospital will take reasonable steps to request that the individual ... sign a written refusal to the Transfer. The written refusal should indicate that the individual ... has been informed of the reasons, risks, and benefits of the Transfer, and should document the reasons for the refusal, if known ...””