The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SUNRISE HOSPITAL AND MEDICAL CENTER 3186 S MARYLAND PKWY LAS VEGAS, NV 89109 Feb. 18, 2011
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure the appropriate transfer forms were completed and medical records forwarded to the receiving facility for the transfer of 1 of 33 patients (Patient #17).

Findings include:

Patient #17

Patient #17 was an [AGE] year-old who (MDS) dated [DATE], with diagnoses of a left hip dislocation. Documentation in the physician's History and Physical (H&P) revealed the patient had hip surgery, Reduction of Slipped Capital Femoral Epiphysis and removal of 3 screws, three weeks prior to admission. The note indicated, "Today, the patient was in school, standing outside on her crutches. A ball hit the patient's crutches causing her to fall on her left hip causing the hip dislocation."

Documentation in the physician's progress notes indicated the ER physician did not call the pediatric orthopedic doctor on call but called the orthopedic doctor who performed the original surgery. The orthopedic doctor came in to see the patient, although he did not have privileges at this facility. The orthopedic doctor recommended the patient be transferred to another facility, where the doctor had privileges, and could re-perform the hip surgery.

Based on the orthopedic surgeon's recommendation, Patient #7 was transferred to Hospital C.

Documentation in the ER physician's History and Physical indicated the ER physician at Hospital B called the ER doctor at Hospital C, and the patient was accepted by the facility.

There was no documented evidence in the medical record the transfer form was completed which indicated the patient was stable for transfer to the receiving facility, and the benefits of transfer outweighed the risk of transfer.

There was no documented evidence the medical record was copied and sent with the patient to the receiving facility.

Documentation in the nurse's notes indicated "19:50 (7:50 PM) Report was given to a nurse via a phone call..." There was no documentation of the nurse's name at the receiving facility who received the report.

On 2/18/11 at 1:00 PM, the Director of Regulatory Compliance confirmed there was no EMTALA transfer form completed.
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on findings at A2404, A2406, A2407, and A2409, the facility failed to ensure compliance with CFR 489.24.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on physician and staff interviews, record review, and document review, the hospital failed to maintain a list of physicians who were on call for duty to provide further evaluation and /or treatment necessary to stabilize an emergency medical condition for 1 of 33 patients (Patient#15).

Findings include:

Patient #15

Medical Record Review

Patient #15 was a [AGE] year old who was seen in the ER of Hospital A (transferring Hospital) on 12/21/10 at 11:47 PM with complaints of right testicular pain, accompanied by vomiting, swelling and redness. Patient #21's history included a right hydrocele repair on 12/21/10 at Hospital A.

Hospital A contacted Hospital B (receiving hospital) at 1:00 AM on 12/22/10, and requested Patient #15 be transferred due to the need for continued medical treatment by a Urologist. Hospital B accepted the transfer of Patient #15.

Patient #15 was then transferred by ground transport, due to weather conditions, and arrived at Hospital B at 4:30 AM, as documented on the triage form.

The ER physician's history indicated an Ultrasound (U/S) of the right testicle was performed at Hospital A which showed no blood flow to the right testicle. A repeat U/S was completed at Hospital B which indicated "heterogeneous right testicle. No arterial blood flow identified compatable (sic) for torsion. There is however, some venous flow. Right scrotal fluid collection. The left testicle is unremarkable."

Documentation on the Intake Coordinator Transfer Flow Sheet on 12/22/10 at 6:40 AM indicated "Urology refused to see pt (patient). Peds (Pediatric) ED called (Dr. Name). (ED Dr. Name) even trying general surgery. Called Hospital C (2nd Receiving Hospital). Spoke to AOD ...She will accept patient."

Consent was obtained for transfer of Patient #15 and the patient was transferred to Hospital C at 7:10 AM for follow up by a Pediatric Urologist.

Document Review

Review of Hospital B's Specialist Call Schedule for December 2010, revealed there were no pediatric urologists on-call for the month. There was documented evidence a urologist was on call for the adult ED (Emergency Department) and for trauma on 12/22/10.

Hospital B's Transfer Checklist had no documented evidence the ER Physician #1 had accepted Patient #15 since the section for PCP (Primary Care Physician) acceptance was left blank.

Interviews

- On 2/18/11 at 3:50 PM, the Vice President of Quality and Medical Staff, (VP of Q&MS) indicated that a call was placed to the adult on-call urologist on 2/18/11. The adult urologist indicated to the VP of Q&MS he remembered the call on 12/22/10, and indicated he was not on-call for pediatrics and only on-call for adults and trauma. The VP of Q&MS verbalized a review of the urologist's contract did not specify a specific age group the urologist would or would not treat. The VP of Q&MS also indicated research was done to review the cases the on-call adult urologist had performed during the 2010 calendar year. The VP of Q&MS indicated there was an elective case done by the On-Call Adult urologist on 9/16/10, which involved an orchiectomy on a [AGE] year-old patient.


- On 2/18/11, the Intake Coordinator (IC) and Chief Operating Officer (COO) of the Children ' s Hospital (Hospital B) were interviewed to obtain additional information about the Intake Coordinator Transfer Flow Sheet. The IC indicated that during the intake process for accepting transfers from another facility, the intake nurse would have called the ED physician for approval. Documentation on Patient #15's Intake form revealed the registered nurse (RN) in the pediatric ED accepted Patient #15.

The IC further acknowledged that the Night Shift Intake Coordinator, who was on duty for Patient #15's transfer, "does know" that there were no pediatric urologists on-call at that time of the transfer.

The COO indicated that from the documentation on the transfer flow sheet, "we were not sure if a pediatric urologist was available at the time of the referral. The COO indicated that pediatric urologists were called, however one was sick, another was out-of-the country and a third had scheduled cases during the morning of 12/22/10. The COO indicated none of the three pediatric urologists called were contracted for scheduled on-call services in the pediatric ED and revealed that in the past, pediatric urologists on staff at Hospital B would consult and/or accept patients from the ED.

- On 2/24/11 at 2:44 PM, the ED physician at Hospital B, indicated he did not verbally accept Patient #15 and denied ever talking to the ED physician from Hospital A requesting the transfer. The ED physician indicated he reminded staff that there were no pediatric urologists on-call in the ED and didn't hear anything for hours. The ED physician then indicated Patient #15 showed up and an assessment was completed. With no urologist available to assess and treat Patient #15, the patient needed to be transferred again.

The ED physician further indicated that attempts were made to get a pediatric urologist, but one had cases in the morning, one was very sick and the third was in Sri Lanka. The ED physician indicated the Urologist on call for the adult ED refused to assess Patient #15 because the testicular torsion was not due to trauma and the patient was a minor.

The ED Physician added the case was even mentioned to a general surgeon passing through the ED. He finished by mentioning he had to "harp" on the charge nurse about not having pediatric urologists on-call.

- On 2/28/11 at 5:00 PM, the Night Shift Intake Coordinator (NSIC) indicated she received a call from Hospital A's ED staff, asking for a transfer. The employee indicated once she received the call, she felt the case should go to the pediatric ED. The NSIC indicated at that time she called the pediatric ED and informed the nurse of the possible transfer, then transferred the call and hung up. The NSIC indicated at that time she was finished with the case, other than faxing the patient's facesheet to the ED.

The NSIC further indicated Hospital B had pediatric urologists at one time. The employee did not decline the transfer because there was a "possibility" to get a urologist. She stated, "I wanted to be sure we can help, so I transferred the call."

The NSIC verbalized it was unknown what happened after the call was transferred. She stated, "there must have been a communication breakdown. I heard the ED Physician at this hospital did not talk with the ED physician from Hospital A." The NSIC also mentioned she doesn't recall talking to the ED Physician at any time during the transfer process of Patient #15.

Based on document review and interviews, the facility failed to ensure the specialist on-call schedule was accurate and staff informed of the current availability of all specialists available for ED Call.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and record review, the facility failed to ensure an appropriate medical screening examination was conducted to rule out a psychiatric emergency prior to discharge for 1 of 33 patients (#11).

Findings include:






Patient #11

Patient #11 was transferred to the emergency room by ambulance on 12/27/2010, for suicidal/homicidal ideations. The patient was diagnosed with alcohol intoxication and substance abuse (marijuana).

Patient #11's Medic West Patient Care Record form indicated an ambulance treated Patient #11 on 12/27/2010. The form documented:

-"...Chief Complaint (Nature of the Emergency/Transfer) Suicidal/Homicidal Idealion(sic)..."
-"...Clinical Impression: r/o (rule out) acute psychosis vs. ingestional behavior..."
-"...Course PTA: pt (patient) found sleeping in park by park police, pt awake stating his wife kicked him out, exibiting suicidal/homicidal statements..."

Patient #11's Clinical Report - Nurses form indicated the patient was triaged on 12/27/2010, at 11:42 AM. The form documented:

-"...Chief Complaint: BIZARRE BEHAVIOR and (SUICIDAL/HOMICIDAL(THREATENED HIS WIFE---)..."

-"...NURSING PROGRESS NOTES 11:50 AM...Suicide precautions initiated:q (every) 15 min checks performed. See restraint documentation (placed into 4 point restraints by Security). (examined by (physician name))..."

Patient #11's Physician Clinical Report form dated 12/27/2010, indicated the patient was examined by the physician at 11:48 AM. The form documented:

-"...HISTORY OF PRESENT ILLNESS Chief Complaint - BEHAVIOR CHANGE and AGITATED, ANGRY and AGGRESSIVE. This started today. He has experienced situational problems related to significant other. The patient exhibited a behavior change. He has been angry and aggressive. Recent alcohol consumption. Last drink was less than 24 hours ago. The patient was not found wandering. Has been very angry. Has exhibited unusual behavior but been eating or sleeping. No self-injury inflicted. The systems are described as moderate. No injury is present. pt denies SI/HI (suicidal/homicidal ideations), states that he was sleeping in the park, and metro awoke him..."

-"...REVIEW OF SYSTEMS The patient has had altered mental status: hostile and combative..."

-"...PHYSICAL EXAM Appearance : Alert. Appearance is normal. The patient is restless and appears hostile and agitated. He shows no apparent trauma but is not ill appearing or toxic appearing or uncooperative..."

Patient #11's ADULT ED LEGAL HOLD (2000) ORDERS form was signed and dated by the physician on 12/27/2010, at 1415. The physician ordered for Benadryl, Haldol, and Ativan to be given as needed. The form had a check mark in the box that read:

-"...Safe discharge when alert, oriented, able to safely ambulate without assistance and tolerate oral intake..."

Patient #11's Adult ED (emergency department) Suicide Risk Factor Scale and Observation Intensity Trigger form was not dated or signed. The form was initiated but was not completed. The risk factors and points in each column were not completed. There was no total score completed to determine what risk level the patient rated.

On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated the Adult ED Suicide Risk Factor Scale and Observation Intensity Trigger form was not complete.

Patient #11's Toxicology report documented Alcohol Blood for the patient was 248 mg/dL (milligrams/deciliter) (D) on 12/27/2010, at 1245 PM. The form documented:

-"...(D) Plasma ethanol levels are 10 - 35% greater than whole blood alcohol levels. A plasma ethanol level of 10-110 mg/dL approximates the >0.08% which legally defines sobriety. Coma may occur when plasma ethanol reaches 300 mg/dL, and death may result when levels exceed 400 mg/dL..."

Patient #11 had a urine toxicology screen completed on 12/27/2010 on 1440 (2:10 PM). The screen was positive for Cannabinoids.

Patient #11's Monitor for Use of Restraint - DOWNTIME form dated 12/27/2010 indicated at 1200, 1300 (1:00 PM), and 1500 (3:00 PM) the patient was combative. The restraints were removed sometime after 4:00 PM.

On 12/27/2010, at 1811 (6:11 PM), Patient #11 was transferred to the DOU (discharge observation unit). The DOU area was located away from the emergency department area and was a locked unit to hold patients. In the unit there were small rooms. Each room was not enclosed but surrounded by 3 walls. The opening to the room had no door and led into a long corridor. One security staff member was always on the unit. There were individual cameras for every room in which the monitor was always observed by the staff.

Patient #11's Clinical Report - Nurses form dated 12/27/2010, documented at 21:11 (9:11 PM):

-"...The patient was discharged home and unaccompanied at the time of discharge. The patient left the Emergency Department ambulatory and via (WILL WALK)..."

There was no documented evidence the patient was reassessed for suicidal/homicidal ideations after his restraints were taken off, after he became calm and cooperative, and before being discharged to go home.

On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated that the physical medical issues should be resolved first before reassessing the psychological status of the patient. The manager indicated Patient #11 was diagnosed with Alcohol Intoxication and Substance Abuse. The Manager indicated Patient #11's psychological status should have been reassessed when the resident had calmed down and was not highly intoxicated.

On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated there was no documented evidence that the patient was psychologically reassessed before his discharge. There was no documented evidence the resident was asked if he continued to have suicidal/homicidal ideations prior to his discharge.

In summary:
On 12/27/2010, at 11:21 AM, Patient #11 was transferred by ambulance to the hospital for possible suicidal/homicidal ideations.
- The Patient was triaged by the nurse and assessed by the emergency room physician. The nursing notes indicated the patient was combative and placed in restraints.
- The physician assessment, completed at 11:48 AM, indicated the patient was not suicidal or homicidal but he also indicated the patient was hostile and agitated.
- The patient's alcohol level obtained at 12:45 PM, was elevated above 0.08% and also had a positive toxicology screen for cannabinoids at 2:40 PM.
- The patient was diagnosed with alcohol intoxication and substance abuse.
- Physician orders written at 2:15 PM, indicated to safely discharge the patient when the patient was alert, oriented, and was able to safely ambulate without assistance.
- The nurse's notes indicated the patient continued to be restrained and combative until 4:00 PM.
- There was no documented evidence that the patient was reassessed by the physician or nurse and asked if he had any suicidal or homicidal ideations after the restraints were discontinued and when he became calm and cooperative.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide continuation of treatment to stabilize an emergency medical condition for 1 of 33 sampled patients (#15).

Findings include:

Patient #15

Medical Record Review

Patient #15 was a [AGE] year old who was seen in the ER of Hospital A (transferring Hospital) on 12/21/10 at 11:47 PM with complaints of right testicular pain, accompanied by vomiting, swelling and redness. Patient #21's history included a right hydrocele repair on 12/21/10 at Hospital A.

Hospital A contacted Hospital B (receiving hospital) at 1:00 AM and requested Patient #15 be transferred due to the need for continued medical treatment by a Urologist. Hospital B accepted the transfer of Patient #15.

Patient #15 was then transferred by ground transport, due to weather conditions, and arrived at Hospital B at 4:30 AM, as documented on the triage form.

The ER physician's history indicated an Ultrasound (U/S) of the right testicle done at Hospital A, showed no blood flow to the right testicle. A repeat U/S was completed at Hospital B which indicated "heterogeneous right testicle. No arterial blood flow identified compatable (sic) for torsion. There is however, some venous flow. Right scrotal fluid collection. The left testicle is unremarkable."

Documentation on the Intake Coordinator Transfer Flow Sheet on 12/22/10 at 6:40 AM indicated "Urology refused to see pt (patient). Peds (Pediatric) ED called (Dr. Name). (ED Dr. Name) even trying general surgery. Called Hospital C (2nd Receiving Hospital). Spoke to AOD ...She will accept patient."

Consent was obtained for transfer of Patient #15 and the patient was transferred to Hospital C at 7:10 AM for follow up by a Pediatric Urologist.

Document Review

Review of Hospital B's Specialist Call Schedule for December 2010, revealed there were no pediatric urologists on-call for the month. There was documented evidence a urologist was on call for the adult ED (Emergency Department) and for trauma on 12/22/10.

Hospital B's Transfer Checklist had no documented evidence the ER Physician #1 had accepted Patient #15 since the section for PCP (Primary Care Physician) acceptance was left blank.

Interviews

- On 2/18/11 at 3:50 PM, the Vice President of Quality and Medical Staff, (VP of Q&MS) indicated that a call was placed to the adult on-call urologist on 2/18/11. The adult urologist indicated to the VP of Q&MS he remembered the call on 12/22/10, and indicated he was not on-call for pediatrics and only on-call for adults and trauma. The VP of Q&MS verbalized a review of the urologist's contract did not specify a specific age group the urologist would or would not treat. The VP of Q& MS also indicated research was done to review the cases the on-call adult urologist had performed during the 2010 calendar year. She indicated there was an elective case done by the On-Call Adult urologist on 9/16/10, which involved an orchiectomy on a [AGE] year-old patient.

- On 2/18/11, the Intake Coordinator (IC) and Chief Operating Officer (COO) of the Children's Hospital (Hospital B) were interviewed to obtain additional information about the Intake Coordinator Transfer Flow Sheet. The IC indicated that during the intake process for accepting transfers from another facility, the intake nurse would have called the ED physician for approval. Documentation on Patient #15's Intake form revealed the registered nurse (RN) in the pediatric ED accepted Patient #15.

The IC further acknowledged that the Night Shift Intake Coordinator, who was on duty for Patient #15's transfer, "does know" that there were no pediatric urologists on-call at that time of the transfer.

The COO indicated that from the documentation on the transfer flow sheet, "we were not sure if a pediatric urologist was available at the time of the referral." The COO indicated that pediatric urologists were called, however one was sick, another was out-of-the country and a third had scheduled cases during the morning of 12/22/10. The COO indicated none of the three pediatric urologists called were contracted for scheduled on-call services in the pediatric ED and revealed that in the past, pediatric urologists on staff at Hospital B would consult and/or accept patients form the ED.

- On 2/24/11 at 2:44 PM, the ED physician indicated he did not verbally accept Patient #15 and denied ever talking to the ED physician from Hospital A requesting the transfer. The ED physician indicated he reminded staff that there were no pediatric urologists on-call in the ED and didn't hear anything for hours. The ED physician indicated Patient #15 showed up and an assessment was completed. With no urologist available to assess and treat Patient #15, the patient needed to be transferred again.

The ED physician further indicated attempts were made to get a pediatric urologist, but one had cases in the morning, one was very sick and the third was in Sri Lanka. The Ed physician indicated the Urologist on call for the adult ED refused to assess Patient #15 because the testicular torsion was not due to trauma and the patient was a minor.

The ED Physician added the case was even mentioned to a general surgeon passing through the ED. He finished by mentioning he had to "harp" on the charge nurse about not having pediatric urologists on-call.

- On 2/28/11 at 5:00 PM, the Night Shift Intake Coordinator (NSIC) indicated she received a call from Hospital A's ED staff, asking for a transfer. The employee indicated once she received the call, she felt the case should go to the pediatric ED. The NSIC indicated at that time she called the pediatric ED, and informed the nurse of the possible transfer, then transferred the call and hung up. The NSIC indicated at that time she was finished with the case, other than faxing the patient's facesheet to the ED.

The NSIC further indicated Hospital B had pediatric urologists at one time. The employee did not decline the transfer because there was a "possibility" to get a urologist. She stated, "I wanted to be sure we can help, so I transferred the call."

The NSIC verbalized it was unknown what happened after the call was transferred. She stated, "there must have been a communication breakdown. I heard the ED Physician at this hospital did not talk with the ED physician from Hospital A." The NSIC also mentioned she doesn't recall talking to the ED Physician at any time during the transfer process of Patient #15.

Evidence through record review, document review and interviews, revealed Hospital B failed to provide continuation of treatment for Patient #15, with a diagnosis of testicular torsion. There were no pediatric urologists under contract for scheduled on-call services for the pediatric ED at the time of the transfer. The scheduled on-call urologist for the adult ED refused to accept Patient #15 due to the urologist's determination the testicle torsion was not due to trauma and the patient was a minor. Patient #15 had to be transferred for a second time to Hospital C to receive continued treatment which caused a delay in medical treatment for Patient #15.