HospitalInspections.org

.
Based on record review and interview, the facility failed to follow the provider's agreement to comply with special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to implement the protocols established in the facility policy "Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure," regarding the availability of on-call physicians, for 1 request for transfer received, out of 1 request reviewed. This failed practice placed the patient and the patient's pregnancy at risk for a delay in emergency medical care.

Findings:

Incident on 12/23/24

Review of facility-provided recorded phone conversations, from a rural Physician Assistant (PA #4) to the facility's call center, on 12/23/24, revealed:

- At 2:12 AM - PA #4 called the facility's call center requesting transfer of a woman (Patient #50) who was 30 weeks pregnant and was experiencing contractions and bleeding. The woman had a history of abruption(a serious pregnancy complication where the placenta separates from the uterine wall before delivery. This can cause heavy bleeding and reduce the baby's supply of oxygen and nutrients). PA #4 further stated he/she had explained that if Patient #50 did deliver, the baby would need a NICU (Neonatal Intensive Care Unit) and that Med Flight was enroute to transport Patient #50. PA #4 requested to talk to an OB provider or if needed, to talk to an ED provider first.

Further review revealed Call Center Nurse #19 stated he/she would put PA #4 through to an OB provider. He/she obtained a call back number for PA #4 and stated he/she would call PA #4 back as soon as he/she got a provider on the line.

- At 2:34 AM, PA #4 called the facility's call center back as he/she had not received a return call from an OB provider. Call Center Nurse #19 state he/she would message OB again and he/she would call PA #4 back.

- At 2:35 AM, Call Center Nurse #19 called the OB unit of the facility. When a nurse from OB answered, Call Center Nurse #19 asked if an OB provider was available. The nurse from OB stated both providers were "both busy right now." When Call Center Nurse #19 inquired how long it would be before one was available the nurse from OB stated he/she did not know "our doc is in the OR and our midwife is in a room." Call Center Nurse #19 ended the call.

- At 2:47 AM, Call Center Nurse #19 called PA #4 back. He/she informed PA #4 that both OB providers were busy and asked when flight would be arriving. PA #4 stated flight would be arriving in 50 to 55 minutes. Call Center Nurse #19 asked if Patient #50 was contracting, PA #4 informed him/her that Patient #50 was contracting every 47 seconds.

Further review revealed that PA #4 stated that since he/she couldn't get a hold of a provider he/she may have to just contact a different facility. Call Center Nurse #19 stated he/she thought that was a good plan and PA #4 ended the call.

Record review on 12/31/24 revealed the facility had EMS/EMTALA protocols established to use when a provider called the facility, using the facility's call center, to request transfer to the facility due to medical emergencies and the need for a higher level of care.

Review of the facility's policy "Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure," last revised 5/1/17, revealed the facility failed to implement the following procedure sections of the policy when PA #4 contacted the facility on 12/23/24 and requested transfer:

Policy Section 4.2 Responsibilities of On-Call Practitioners:

1) ". . . 4.2.1 In general, on-call practitioners are expected to respond to pagers and return telephone calls within 15 minutes and to be available on site within 60 minutes if requested by a treating practitioner or designee . . ."

During an interview on 12/31/24 at 10:58 AM, the Clinical Nurse Manager (CNM) of the Central Nursing Office (the call center's manager), stated it was the expectation of all nurses in the call center to connect providers who call with a facility provider. Once connected the facility provider will have a conversation with the provider who called and determine if an admission is warranted or if they should go to a different hospital. The CNM of the Central Nursing Office further stated that when the call center pages or tiger texts (online communication tool) a facility provider, there was a 20-minute call back timeframe for providers.

Review of the facility document, "Admitting Notification Worksheet," the call center's log of PA #4's phone contact, dated 12/23/24, revealed On-Call OB Provider #1 was paged on 12/23/24 at 2:15 AM.

2) ". . . 4.2.4 Practitioners who are treating another patient when paged or called must respond within the timeframes established by this or other applicable procedures to inform the attending practitioner when the practitioner can discuss the case with the treating practitioner, consult about the type of care to be provided to the individual until the on-call practitioner can personally attend to the individual of requested, and, if necessary, implement the back-up plan . . ."

Review of the call center's telephone recording on 12/23/24 at 2:35 AM, revealed one OB Provider was in an OR and the midwife was in a room, however, did not clarify what the midwife was doing in the room. Further review revealed Call Center Nurse #19 did not ask if the midwife could step out to speak on the phone.

Review of the facility document, "Admitting Notification Worksheet," dated 12/23/24, revealed no documentation when On-Call OB Provider #1 returned the page to contact the call center. Further review revealed no documentation of a second page for On-Call OB Provider #1.

Policy Section 4.4 Alternatives

3) ". . . 4.4 Alternatives: If no practitioner with the needed specialty is on-call or if the on-call practitioner is not available or does not respond or appear within a reasonable time, the treating practitioner may . . . 4.4.2 use other available resources to meet the individual's needs, including other on-site or on-call practitioners . . ."

During an interview on 12/31/24 at 10:58 AM, when asked what the protocol was for the nurses of the call center when the provider didn't call back, the CNM of the Central Nursing Office stated the nurses would attempt to call back several times, but if that was unsuccessful the nurses would contact an ED doctor to talk to the provider who called.

Review of the facility's on-call schedule dated, 12/22-23/24, revealed two OB/GYN (obstetrics and gynecology) practitioners were on call for 12/22-23/24, On-Call OB Provider #1 and On-Call OB Provider #62. Neither of these providers were a midwife.

Further review of the facility document, "Admitting Notification Worksheet," dated 12/23/24, revealed no documentation to attempt to contact On-Call OB Provider #62. Further review revealed no attempt to contact an ED provider.

During an interview on 12/31/24 at 11:30 AM, when asked, because OB provider #1 did not respond to the page on 12/23/24, if Call Center Nurse #19 should have contacted an ED provider, the CNM of the Central Nursing Office stated Call Center Nurse #19 should have connected PA #4 with an ED provider.

Policy Section 4.5 Mandatory Reporting

4) ". . . 4.5 Mandatory Reporting: ANMC staff must make the following reports to ensure compliance with the EMS/EMTALA Policy and related procedures and other applicable requirements and to facilitate adequate tracking required for quality and performance improvement processes. 4.5.1 The treating practitioner or designee will promptly report an on-call practitioner's unavailability, refusal, lack of timely response or appearance and/or the inadequacy of any back up plan to: 4.5.1.1 Relevant [facility] peer review or performance improvement body; and 4.5.1.2 the SCMD [Service Center Medical Directors] (or CMO [Chief Medical Officer] if it is the SCMD who did not respond timely). 4.5.2 The report will be made even if the treating practitioner thinks the circumstances were beyond the on-call practitioner's control . . ."

During an interview on 12/31/24 at 10:58 AM, when asked if there was a protocol the call center nurses used when they were unable to make contact with a provider, the interim Chief Nursing Officer stated the nurses would alert the AOC (Administrator on call) to inform them there was a problem contacting a provider. The AOC would then alert other higher-level leaders and risk management, and they would complete an investigation.

During the course of this survey, on 12/31/24, no documentation was found to support the facility's mandatory reporting protocols were implemented.

During an interview on 12/31/24 at 11:33 AM, the interim Chief Nursing Officer stated that after hearing the 12/23/24 recorded phone conversation with PA #4, there was room for improvement in the call center's actions.

Rural Clinic Medical Record Review

Review of the rural clinic's Physician Note for Patient #50, dated 12/23/24, revealed: ". . . I spoke with the ED physician at FMH [Fairbanks Memorial Hospital] and we decided that since the patient seems to be going into labor and the fetus his age was unknown, but had a high likelihood of needing to go to the NICU, we decided that it would be best to send the patient directly to Anchorage. I spoke with the transfer center at ANMC [Alaska Native Medical Center], but both of their OBs on-call were unable to take my calls x 2 due to being in surgery . . ."

Review of the facility policy "Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) General Procedure," last revised 5/1/17, revealed: "ANMC staff will provide an appropriate Medical Screening Examination and necessary stabilizing treatment and/or an appropriate transfer to all individuals at ANMC in accordance with the EMS/EMTALA Policy and related procedures . . ."
.

.
Based on interview and observation, the facility failed to ensure signage informing patients of the Emergency Medical Treatment and Labor Act (EMTALA) was posted at 1 out of 2 entrances to the Emergency Department (ED). This failed practice denied patients access to information about their right to a Medical Screening Exam.

Findings:

During an interview on 12/31/24 at 8:30 AM, the Manager of the ED stated that there were two entrances into the ED. One was for walk-in patients and the other was for the ambulance personnel to bring patients in on gurneys.

An observation on 12/31/24 at 8:30 AM, revealed there was EMTALA signage in the entryway of the walk-in entrance. Further observation revealed there was no EMTALA signage in the entryway of the ambulance personnel/gurney entrance.

During an interview on 12/31/24 at 8:52 AM, the interim Chief Nursing Officer stated that signs in the ambulance personnel/gurney entrance were taken down to get framed.

Review of the facility's policy "Emergency Medical Treatment and Labor Act (EMTALA) Policy," last reviewed 9/7/24, revealed: ". . . ANMC shall post a sign in a conspicuous area(s) of the Emergency Services Department, entrance, admitting areas, waiting room, treatment areas, etc., specifying the rights of the individual with respect to examination and treatment of medical conditions and women in labor . . ."
.

.
Based on record review and interview, the facility failed to implement the protocols established in the facility policy "Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure," regarding the availability of on-call physicians, for 1 request for transfer received, out of 1 request reviewed. This failed practice placed the patient and the patient's pregnancy at risk for a delay in emergency medical care.

Findings:

Incident on 12/23/24

Review of facility-provided recorded phone conversations, from a rural Physician Assistant (PA #4) to the facility's call center, on 12/23/24, revealed:

- At 2:12 AM - PA #4 called the facility's call center requesting transfer of a woman (Patient #50) who was 30 weeks pregnant and was experiencing contractions and bleeding. The woman had a history of abruption(a serious pregnancy complication where the placenta separates from the uterine wall before delivery. This can cause heavy bleeding and reduce the baby's supply of oxygen and nutrients). PA #4 further stated he/she had explained that if Patient #50 did deliver, the baby would need a NICU (Neonatal Intensive Care Unit) and that Med Flight was enroute to transport Patient #50. PA #4 requested to talk to an OB provider or if needed, to talk to an ED provider first.

Further review revealed Call Center Nurse #19 stated he/she would put PA #4 through to an OB provider. He/she obtained a call back number for PA #4 and stated he/she would call PA #4 back as soon as he/she got a provider on the line.

- At 2:34 AM, PA #4 called the facility's call center back as he/she had not received a return call from an OB provider. Call Center Nurse #19 state he/she would message OB again and he/she would call PA #4 back.

- At 2:35 AM, Call Center Nurse #19 called the OB unit of the facility. When a nurse from OB answered, Call Center Nurse #19 asked if an OB provider was available. The nurse from OB stated both providers were "both busy right now." When Call Center Nurse #19 inquired how long it would be before one was available the nurse from OB stated he/she did not know "our doc is in the OR and our midwife is in a room." Call Center Nurse #19 ended the call.

- At 2:47 AM, Call Center Nurse #19 called PA #4 back. He/she informed PA #4 that both OB providers were busy and asked when flight would be arriving. PA #4 stated flight would be arriving in 50 to 55 minutes. Call Center Nurse #19 asked if Patient #50 was contracting, PA #4 informed him/her that Patient #50 was contracting every 47 seconds.

Further review revealed that PA #4 stated that since he/she couldn't get a hold of a provider he/she may have to just contact a different facility. Call Center Nurse #19 stated he/she thought that was a good plan and PA #4 ended the call.

Record review on 12/31/24 revealed the facility had EMS/EMTALA protocols established to use when a provider called the facility, using the facility's call center, to request transfer to the facility due to medical emergencies and the need for a higher level of care.

Review of the facility's policy "Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure," last revised 5/1/17, revealed the facility failed to implement the following procedure sections of the policy when PA #4 contacted the facility on 12/23/24 and requested transfer:

Policy Section 4.2 Responsibilities of On-Call Practitioners:

1) ". . . 4.2.1 In general, on-call practitioners are expected to respond to pagers and return telephone calls within 15 minutes and to be available on site within 60 minutes if requested by a treating practitioner or designee . . ."

During an interview on 12/31/24 at 10:58 AM, the Clinical Nurse Manager (CNM) of the Central Nursing Office (the call center's manager), stated it was the expectation of all nurses in the call center to connect providers who call with a facility provider. Once connected the facility provider will have a conversation with the provider who called and determine if an admission is warranted or if they should go to a different hospital. The CNM of the Central Nursing Office further stated that when the call center pages or tiger texts (online communication tool) a facility provider, there was a 20-minute call back timeframe for providers.

Review of the facility document, "Admitting Notification Worksheet," the call center's log of PA #4's phone contact, dated 12/23/24, revealed On-Call OB Provider #1 was paged on 12/23/24 at 2:15 AM.

2) ". . . 4.2.4 Practitioners who are treating another patient when paged or called must respond within the timeframes established by this or other applicable procedures to inform the attending practitioner when the practitioner can discuss the case with the treating practitioner, consult about the type of care to be provided to the individual until the on-call practitioner can personally attend to the individual of requested, and, if necessary, implement the back-up plan . . ."

Review of the call center's telephone recording on 12/23/24 at 2:35 AM, revealed one OB Provider was in an OR and the midwife was in a room, however, did not clarify what the midwife was doing in the room. Further review revealed Call Center Nurse #19 did not ask if the midwife could step out to speak on the phone.

Review of the facility document, "Admitting Notification Worksheet," dated 12/23/24, revealed no documentation when On-Call OB Provider #1 returned the page to contact the call center. Further review revealed no documentation of a second page for On-Call OB Provider #1.

Policy Section 4.4 Alternatives

3) ". . . 4.4 Alternatives: If no practitioner with the needed specialty is on-call or if the on-call practitioner is not available or does not respond or appear within a reasonable time, the treating practitioner may . . . 4.4.2 use other available resources to meet the individual's needs, including other on-site or on-call practitioners . . ."

During an interview on 12/31/24 at 10:58 AM, when asked what the protocol was for the nurses of the call center when the provider didn't call back, the CNM of the Central Nursing Office stated the nurses would attempt to call back several times, but if that was unsuccessful the nurses would contact an ED doctor to talk to the provider who called.

Review of the facility's on-call schedule dated, 12/22-23/24, revealed two OB/GYN (obstetrics and gynecology) practitioners were on call for 12/22-23/24, On-Call OB Provider #1 and On-Call OB Provider #62. Neither of these providers were a midwife.

Further review of the facility document, "Admitting Notification Worksheet," dated 12/23/24, revealed no documentation to attempt to contact On-Call OB Provider #62. Further review revealed no attempt to contact an ED provider.

During an interview on 12/31/24 at 11:30 AM, when asked, because OB provider #1 did not respond to the page on 12/23/24, if Call Center Nurse #19 should have contacted an ED provider, the CNM of the Central Nursing Office stated Call Center Nurse #19 should have connected PA #4 with an ED provider.

Policy Section 4.5 Mandatory Reporting

4) ". . . 4.5 Mandatory Reporting: ANMC staff must make the following reports to ensure compliance with the EMS/EMTALA Policy and related procedures and other applicable requirements and to facilitate adequate tracking required for quality and performance improvement processes. 4.5.1 The treating practitioner or designee will promptly report an on-call practitioner's unavailability, refusal, lack of timely response or appearance and/or the inadequacy of any back up plan to: 4.5.1.1 Relevant [facility] peer review or performance improvement body; and 4.5.1.2 the SCMD [Service Center Medical Directors] (or CMO [Chief Medical Officer] if it is the SCMD who did not respond timely). 4.5.2 The report will be made even if the treating practitioner thinks the circumstances were beyond the on-call practitioner's control . . ."

During an interview on 12/31/24 at 10:58 AM, when asked if there was a protocol the call center nurses used when they were unable to make contact with a provider, the interim Chief Nursing Officer stated the nurses would alert the AOC (Administrator on call) to inform them there was a problem contacting a provider. The AOC would then alert other higher-level leaders and risk management, and they would complete an investigation.

During the course of this survey, on 12/31/24, no documentation was found to support the facility's mandatory reporting protocols were implemented.

During an interview on 12/31/24 at 11:33 AM, the interim Chief Nursing Officer stated that after hearing the 12/23/24 recorded phone conversation with PA #4, there was room for improvement in the call center's actions.

Rural Clinic Medical Record Review

Review of the rural clinic's Physician Note for Patient #50, dated 12/23/24, revealed: ". . . I spoke with the ED physician at FMH [Fairbanks Memorial Hospital] and we decided that since the patient seems to be going into labor and the fetus his age was unknown, but had a high likelihood of needing to go to the NICU, we decided that it would be best to send the patient directly to Anchorage. I spoke with the transfer center at ANMC [Alaska Native Medical Center], but both of their OBs on-call were unable to take my calls x 2 due to being in surgery . . ."

Review of the facility policy "Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) General Procedure," last revised 5/1/17, revealed: "ANMC staff will provide an appropriate Medical Screening Examination and necessary stabilizing treatment and/or an appropriate transfer to all individuals at ANMC in accordance with the EMS/EMTALA Policy and related procedures . . ."
.