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Based on staff interview and record review, the hospital failed to comply with 42 CFR ? 489.24, Special Responsibilities of Medicare hospitals in emergency services. This failure compromised the well being of one (Patient 1) of 30 patients reviewed and could potentially affect other patients in need of emergency services.

Findings:

During the EMTALA survey conducted on 12/1/10 and 12/2/10, the survey team determined that the hospital failed to provide an appropriate medical screening examination to Patient 1.

Patient 1 presented to the Emergency Department following a fall with trauma to the the left eye and left eyebrow laceration. He received sutures for the eyebrow laceration but did not receive appropriate evaluation of the eye itself which had sustained a ruptured globe. Patient 1 was discharged home. The ruptured globe was detected when Patient 1 returned five days later for removal of the eyebrow sutures.

Failure to provide an appropriate medical screening for Patient 1's eye condition increased the likelihood he would lose his eye, which he did five days later.

Based on staff interview and record review, the hospital failed to provide an appropriate medical screening examination to one (Patient 1) of 30 patients reviewed. Patient 1 presented to the Emergency Department following a fall with trauma to the the left eye and left eyebrow laceration. He received sutures for the eyebrow laceration but did not receive appropriate evaluation of the eye itself which had sustained a ruptured globe. Patient 1 was discharged home. The ruptured globe was detected when Patient 1 returned five days later for removal of the eyebrow sutures.

Failure to provide an appropriate medical screening for Patient 1's eye condition increased the likelihood he would lose his eye, which he did five days later.

Findings:

Record review on 12/1/10 showed that Patient 1, an 89 year old male and retired physician, presented to Hospital A's Emergency Department (ED) on 12/1/08 at 10:38 a.m. with a chief complaint of "laceration of head". The triage nurse documented the patient's stated history, "Heard a noise this morning and jumped out of bed and fell hitting left eye on a desk". Initial pain assessment by the nurse at 10:57 a.m. showed, "...pain score 6 (on a 0-10 scale, 10 being the highest severity level of pain); left eye; aching; continuous".

At 10:57 a.m. Physician A initiated the medical screening examination and completed it at 11:08 a.m. Physician A documented under "History of Present Illness" that Patient 1 was, "Here for eval(uation) of left eyebrow lac(eration)." The physical exam noted a "3.5 cm laceration to left eyebrow, no orbital stepoff/deformities (no signs of a fracture of the eye socket); left eye status/post surgical changes; R (right) pupil reactive (eye nerve normal)." There was no mention in Patient 1's medical screening examination of the patient's reported eye pain nor a reassessment of his pain prior to discharge from ED. There was no mention of the condition of the eye globe nor of a need for a possible ophthalmology consult to rule out any eye injury after a fall with eye trauma.

Further record review on 12/1/10 showed that Patient 1's laceration was sutured closed and he was discharged home with a scheduled follow up appointment in five days for suture removal.

Patient 1 returned to the Minor Injury Clinic of the ED as scheduled on 12/6/08. Physician B documented in the ED note that Patient 1 presented for suture removal "...as well as loss of vision in the left eye...Pt. (patient) states he was able to see in the periphery but now he cannot see anything even light. He reports slight ache in the left eye." Physician B examined Patient 1 and called an ophthalmologist (eye specialist) for consultation. At 1:00 p.m. the ophthalmologist found that Patient 1 had a left ruptured globe and an infection of the eye and "...will need enucleation" (surgical removal of the eye globe).

Medical record review on 12/1/10 showed that Patient 1 had a past medical history of a previous ruptured left eye globe, as well as left eye cataract surgery and left eye corneal transplantation. His vision in the left eye was for hand motion only.

In an interview on 12/1/10 at 2:00 p.m., the Department Chief of Ophthalmology said, "An ophthalmology consult could have made the diagnosis of a ruptured globe" and that "there was a chance it could have been repaired" which "might have prevented the infection". He explained that given Patient 1's history of extensive eye surgeries and previous trauma, his left eye was not normal and likely had some disruption of the nerves to the eye and lowered the level of pain sensation. He said that a ruptured globe is normally quite painful yet this patient did not appear to be in great pain.

Physician A was interviewed on 12/1/10 at 3:00 p.m. He stated that Patient 1 had no signs or symptoms of a head injury and no eye pain. He stated that "only a limited eye exam was possible due to the patient's eyelid being swollen shut". He stated that he was able to look at the eye and that the surface was irregular due to prior surgeries. There was no examination of the inside of Patient 1's left eye with an eye scope (instrument used to examine the inside of the eye with a magnified light source) which could have shown signs of a ruptured globe. When asked why there was no consult, Physician A replied that the "patient had a lack of eye pain and no signs or symptoms of an acute eye injury, I focused on the chief complain of laceration". Physician A also stated during the interview, "I did a gross, quick exam of the left eye".