Summerlin Hospital Medical Center

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39418 Based on interview, record review and document review, the facility failed to ensure a complete medical screening exam (MSE) and consistent pain monitoring was completed during the emergency department (ED) visit for 1 of 27 sampled patients (Patient 13). The deficient practice had a potential for not establishing stability and the need for a transfer to a higher level of care. Findings include: Patient 13 (P13) presented to the ED on 07/28/2025 with a chief complaint of contact stuck in the right eye. The ED Triage Primary Pain Assessment timed at 1:27 AM, entered by the Triage registered nurse (RN) documented: Primary Pain Location: Eye Primary Pain Laterality: Right Pain Assessment Tool Utilized: Numeric Numeric Pain Scale: 8 The ED Physician Record documented the patient was seen on 07/28/2025 at 1:45 AM. The History of Present Illness documented the patient presented with a chief complaint of a contact stuck in the right eye. The patient stated the contact had been there for approximately 24 hours. The patient was seen by an optometrist earlier in the day who was unable to remove it. The optometrist gave the patient a referral to an ophthalmologist in the morning. The patient was unable to tolerate the pain. The character of symptoms was pain and redness. The type of foreign body was contact. The degree of symptoms was moderate. The exacerbating factor was light. A Review of Systems revealed eye pain. The Physical Examination documented pupils were equal, round and reactive to light, extraocular movements were intact, conjunctiva was red and infected. Contact was visualized. Method of inspection: right eye, viewed with fluorescein, viewed with slit lamp, Tetracaine applied. The ED Physician Record lacked documentation the patient’s visual acuity (basic test to check how well a patient sees) was assessed and if the patient was experiencing any vision changes from the current chief complaint. The Reexamination/ Reevaluation completed on 7/28/2025 at 6:03 AM, documented the patient presented with contact stuck in the right eye. Vitals signs at triage were unremarkable. Please see above charting for medications which were ordered. Multiple attempts were made utilizing multiple different methods, all of which were unsuccessful. The patient will be discharged with erythromycin medication. The patient will be given several referrals for different possible eye clinics. The patient evaluated and medical data reviewed as available. Patient resting comfortably. Patient was afebrile and nontoxic in appearance and in no acute distress. Discussed with patient diagnosis. Discussed with patient treatment plan. All questions answered. Strict return precautions given. The patient requested to be discharged home. The patient agreed to comply with treatment plan. The attending physician documented participating in the following activities of the patient’s care: performed a substantive part (at least 50%) of the Medical Decision Making (MDM) during the patient’s ED visit and evaluated the patient myself. The Fluorescein Staining Eye Procedure Note documented the following: - Right eye -Anesthetized with tetracaine (local anesthetic used to numb specific body parts, primarily the eyes, nose, and skin, before medical procedures) 2 drops (gtts) - Fluorescein uptake across the entire pupil suggestive of retained contact - Right eye rinsed with eye wash. The patient tolerated well - procedure performed by ED Attending Physician. Multiple attempts were made to try to dislodge the patient’s contact. Used 1 Liter of Normal Saline and a Morgan lens as well as the Woods lamp and a slit lamp. After unsuccessful flushing of the eye with a Morgan lens, attempted to dislodge the contact using a blunt needle using the slit lamp. Used erythromycin ointment to try to soften the contact and reattempted to remove the contact but was unsuccessful. The patient instructed to follow-up with ophthalmology in the morning The reexamination and attending physician addendum notes lacked medical screening for visual acuity. The lack of initial and reexamination MSE on visual acuity failed to clarify if the patient’s visual condition was improving or worsening. There was lack of procedural notes performed by the attending physician in removing the contact lens through various procedures. The lack of properly documented procedural notes failed to create a detailed, official record of a medical procedure, detailing the procedure: Name, date, time, and indication (why it was done). Technique: Description of the surgical approach. Findings: What was observed during the procedure. Post-Procedure: effectiveness of the procedure, patient tolerating the procedure and post operative pain. On 11/05/2025 at 9:36 AM, the ED Manager confirmed the procedural note for the removal of the foreign body in the patient’s right eye was the one incorporated in the ED physician’s note. The Manager indicated the ED did not have an ophthalmologist on call, if the patient needed an emergent ophthalmologist, then a transfer to higher level of care would be initiated. The ED Nursing Special Case Note documented by the RN on 07/28/2025 at 5:15 AM, wrote at 5:05 AM, this RN assumed care of the patient and placed patient in a gown. The patient side rails were up, and call light was in reach. This RN tied together hospital socks inside-out and placed on patient’s face so the patient’s eyes would remain closed to prevent further damage from a foreign body. The RN documented on 07/28/2025 at 5:46 AM, Nursing note: At 5:40 AM, this RN was at bedside with the patient and attending physician. At 5:46 AM, attending physician attempted to remove patient’s contact lenses from right eye. At 5:47 AM attending physician instructed the patient to go to the ophthalmologist to remove patient’s foreign body from eye. At 5:49 AM, the attending physician stated unsuccessful last attempt and removal. The ED Nurse Reassessment entered by the RN on 07/28/2025 at 6:37 AM, documented patient ambulatory with steady gait. Patient was alert and oriented X4 and had all belongings. The patient still had a foreign body in the right eye, and the patient verbalized understanding to see eye doctor near campus, as stated on discharge paperwork. The patient verbalized understanding of discharge paperwork, and the patient had no new prescriptions at this time. The patient had no intravenous lines to remove. The patient’s wristband was removed. The discharge care plan documented the patient ambulated without assistance, was discharged to a private vehicle with the patient’s spouse, with instructions patient instructed not to drive home. The ED Clinical Summary dated 07/28/2025 at 6:49 AM, documented under “Functional Status” affect/behavior: crying. The patient was provided with educational materials for “corneal injury, contact lens”. The ED record lacked documented evidence that the patient’s condition was assessed from 1:27 AM (triage) to 5:05 AM (entered nurses note) with regards to patient’s pain and current condition. The facility policy titled “EMTALA - Emergency Medical Treatment and Labor Act”, last reviewed on 02/2025, documented, Medical Screening Examination (MSE) was the process (which begins with the initial collection of an individual’s vital signs and other medical data collection) required to reach with reasonable clinical confidence, the point at which it could be determined whether or not an Emergency Medical Condition (EMC) exists. Screening was to be conducted to the extent necessary, by physicians and/or other qualified medical personnel (QMP) to determine whether an EMC exists. Establishing Medical Stabilization. The determination of whether an individual was stable was not based on the clinical outcome of the individual’s medical condition. An individual had been provided with sufficient Stabilizing Treatment. when: 1. Stable. The physician or QMP treating the Emergency Medical Condition and providing the medical screening had determined, within reasonable clinical confidence, that the EMC that caused the individual to seek care in the ED was resolved although the underlying medical condition may persist. Once the individual was stable, EMTALA no longer applied.”

“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: 39418 Based on interview, record review and document review, the facility failed to provide documented evidence of discussions of treatment options after an unsuccessful medical treatment in the Emergency Department (ED) for 1 of 27 sampled patients (Patient 13). The deficient practice had potential for a patient not to be informed of the risk and the benefits of all treatment options to make an informed decision. Findings include: Patient 13 (P13) presented to the ED on 07/28/2025 at 1:45 AM, the admitting ED physician documented the initial assessment. The patient presented with contact stuck in the right eye. The patient stated it had been there for approximately 24 hours. The patient went and saw an optometrist earlier in the day who was unable to remove it. The optometrist gave the patient a referral to an ophthalmologist in the morning. The patient was unable to tolerate the pain. The onset was 24 hours ago. The location where the incident occurred was at home. The character of symptoms is pain and redness. The type of foreign body was a contact lens. The degree of symptoms was moderate. The exacerbating factor was light. The physical exam revealed the pupils were equal, round and reactive to light, extraocular movements were intact, conjunctiva was red and injected. Contact visualized. Method of inspection: right eye, viewed with fluorescein, viewed with slit lamp. Tetracaine applied. Medication orders included: Erythromycin 0.5% ophthalmic ointment: 1 app, left eye once and right eye once Fluorescein 1 milligram ophthalmic test: 1 app, right eye once Tetracaine 0.5% ophthalmic solution: 1 drops, right eye once The Reexamination/ Reevaluation documentation dated 07/28/2025 at 6:03 AM, documented “ ...Utilizing several different ways. All were unsuccessful... presents with contact stuck in the right eye. Vitals signs at triage were unremarkable. Please see above charting for medications which were ordered. Multiple attempts were made utilizing multiple different methods, all of which were unsuccessful. Patient will be discharged with erythromycin. [The patient] will be given several referrals for different possible eye clinics. Patient evaluated and medical data reviewed as available. Patient resting comfortably. Patient is afebrile, nontoxic in appearance and in no acute distress. Discussed with patient diagnosis. Discussed with patient treatment plan. All questions answered. Strict return precautions given. Patient requesting to be discharged to home. Patient agrees to comply with treatment plan.” The Impression and Plan documented contact lens stuck, patient’s condition stable. Patient 13 was given educational materials for corneal injury, contact lens. An Addendum entry was completed by the Attending Physician and documented; “I participated in the following activities of this patient’s care: I performed a substantial part (at least 50%) of the medical decision making during the patient’s emergency visit. I evaluated the patient myself. Fluorescein Staining Eye Procedure Note: - Right eye -Anesthetized with Tetracaine 2 drops (gtts) - Fluorescein uptake across the entire pupil suggestive of retained contact - Right eye rinsed with eye wash. The patient tolerated well. - Multiple attempts were made to try to dislodge the patient’s contact. We used 1 liter of normal saline and a Morgan lens (a medical device used for continuous eye irrigation, especially for chemical or thermal burns and for flushing out foreign materials) as well as the Woods lamp (a diagnostic tool that uses long-wave ultraviolet (UV) light, also known as black light, to examine the dye reactions) and a slit lamp (a special binocular microscope with a high-intensity light source that an eye doctor uses to examine the eye’s front and back structures in great detail). After unsuccessful flushing of the eye with a Morgan lens, I attempted to dislodge the contact using a blunt needle using the slit lamp. I also used erythromycin ointment to try to soften the contact and reattempted to remove the contact but was unsuccessful. The patient instructed to follow-up with ophthalmology in the morning. Risk: Based upon my evaluation, this patient is suffering from an ACUTE condition which requires emergent treatment ...Based upon my initial history and physical examination, this patient appeared to be at risk for: See “MDM Notes” for other diagnosis which have been considered and ruled out ...” A Nursing Note dated 07/28/2025 at 5:47 AM, documented physician instructed patient to go to ophthalmologist to remove foreign body from eye. The Discharge Nursing Note dated 07/28/2025 at 6:37 AM, documented the patient was ambulatory with steady gait. The patient was alert and oriented and had all belongings. The patient still had foreign body in the right eye, and the patient verbalized understanding to see eye doctor near campus, as stated on discharge paperwork. The patient verbalized understanding of discharge paperwork and had no new prescriptions at this time. The patient had no intravenous line to remove. The patient’s wristband was removed. This nurse initialed discharge. On 11/05/2025 at 9:36 AM, the ED Manager confirmed the procedural note for the removal of the foreign body in the patient’s right eye was the one incorporated in the ED physician’s note. Fluorescein was a dye used to identify any foreign object in the eye in conjunction with the use of different lamps. The ED manager confirmed the ED attending physician was practicing as an emergency medicine, not an ophthalmologist. The ED Manager indicated there was no specific plan of care or clinical practice guidelines outlining the care of a foreign body in an eye. The manager indicated the treatment was based on the presented symptoms and patient care needs. Example, the approach would be different from an eye puncture to a chemical splash to the eyes; such instances would require stabilization and possibly a transfer to higher level of care. The ED Manager indicated contact lenses at times could be worn for long periods of time and normally did not pose any risk. The Manager indicated the ED did not have an ophthalmologist on call, if the patient needed an emergent ophthalmologist, then a transfer to higher level of care would be initiated. On 11/05/2025 at 12:10 PM, interview with an ED Physician regarding the treatment plan for foreign body (contact lens used as an example) claimed to be stuck in the right eye. The physician first asked if the patient had been seen by another provider. If the patient had been seen by a specialist - in this case an optometrist, there was a good chance the optometrist should have been able to remove the lodged contact lens. If the patient presented in the ED with pain in the affected eye, the physician would first numb the affected eye then stain it with Fluorescein dye. The physician would then examine the eye utilizing a woods lamp and decide from there if the eye had a foreign object for removal. Dye uptake could signify different things, it could be a foreign object, scar or abrasion. The physician indicated if the removal was not successful the patient should then be referred to an optometrist or an ophthalmologist. On 11/07/2025 at 9:20 AM, a phone interview was conducted with the ED physician involved with the care of the patient. The physician indicated remembering the incident. The physician recapped the care that was provided to the patient initially starting from flushing with NS, lubricating the eye and instilling dye then using the specialized eye equipment to properly visualize the eye. The ED physician indicated using a Blunt needle (a needle with no sharp tip) and not a straight needle to attempt to remove the stuck contact lens. The ED physician confirmed a blunt needle was the usual instrument used by ED physicians when removing foreign objects/materials in the eye. The ED physician confirmed not using a scalpel to remove the foreign object. The ED physician indicated a transfer to a higher level of care would have been needed if the situation was “Emergent”. The ED physician recalled the patient requested to be discharged and the patient indicated already having an appointment. The patient was referred to an ophthalmologist based on the ED discharge instructions. The Emergency Room Call Schedule was reviewed from May to October 2025, and revealed no ophthalmologist was on the list. The medical record lacked documented evidence the ED physician discussed with the patient an option to be transferred to another hospital with ophthalmology services for further treatment. The ED record lacked documented evidence of a discussion with the patient regarding other treatment options besides the referral after an unsuccessful medical treatment in the ED.”