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Based on record review and interview the facility failed to ensure 1 patient (#11), of 22 reviewed, who presented to the Emergency Department (ED) for an emergency medical condition, was offered a medical screening exam (MSE). This failed practice caused a delay in intervention and treatment and potentially delayed emergency responders transporting the patient, from responding to other calls.
Findings:

Review of a facility reported incident on 10/05/21, revealed on "September 1st at 10:57 PM ARH [Alaska Regional Hospital] went on full hospital closure ...at 11:15 PM on September 1st, the Anchorage Fire Department (AFD) EMS [emergency management system] radioed to ARH indicating they were transporting a Patient to the department from the Department of Corrections (DOC). The Patient was a 73-year-old male with a chief complaint of chest pain, [shortness of breath], hypertension [high blood pressure] ...employee who received the EMS radio communication did not reiterate that ARH was on closure per the earlier notice to the AFD dispatch."

At 11:19 PM "EMS arrived at ARH's ambulance bay. As the EMS crew prepared to unload the patient the Emergency Department (ED) Charge Nurse [Licensed Nurse (LN) #3] presented to the ambulance bay and explained to the crew the hospital is on hospital closure and the ED could not accept the patient. The EMS crew then departed to [Hospital B].

The following morning (September 2nd), AFD notified ARH's EMS Outreach Manager of the event that had occurred."

"Timeline
[10:55 PM]-Administrator on call notified of ARH's capacity status and the decision was made to put the ARD on closure due to capacity.
[10:57 PM]-Hospital listed in AFD Dispatch status board as closed
[11:15]-Medic 1 radioed report, report accepted by ARD ED staff (did not indicate facility closure).
[11:19 PM]-Medic 1 arrived in ambulance bay and met by [Licensed Nurse (LN) #3].
[11:21 PM]-Medic 1 departed ARH ambulance bay and proceeded to [Hospital B]. ARH the entered the patient on its Central Log as a "John Doe".

Further review of the facility reported incident revealed "The Following Correction Actions Have Been taken:
1. [Name] Chief Executive Officer [CEO] and [Name] Chief Medical Officer [CMO] for ARH contacted AFD [Anchorage Fire Department] Battalion Chief [Name] and Fire/EMS Operations Medical Director [Name], on September 2nd to follow up on the occurrence and be transparent about what occurred.

2. Also on September 2nd, during the daily 'Huddle' with all department leadership and/ or representatives, [name] Ethics and Compliance officer educated staff on EMTALA [Emergency Medical Treatment and Active Labor Act] using this incident as a learning tool. The 'ask' was to take back the information and begin the re-education of staff.

3. Workforce members are being re-educated on ARH's EMTALA Medical Screening Exam Policy. This will include ED Nurses, House Supervisors, Patient Care Attendants and Certified Nurse Aides and is now in process.

4. Re-education will include any and all ED staff authorized to meet EMS at the ambulance bay and to stress that even if ARH is on closure or diversion, if EMS shows up, the patient has 'presented to the ED', EMTALA applies and the required MSE and stabilizing treatment will be given. ED Charge Nurses will communicate at department huddle. There will also be individual rounding with ED employees on EMTALA as directed by the chief nursing officer.

5. Doctor [CMO] will bring awareness of the incident provide re-education of ARH's EMTALA policies to ARH's Emergency Room physicians."

Record Review:

On 10/5/21, review of the Emergency Medical Treatment and Active Labor Act [EMTALA] emergency Department [ED] log at ARH revealed Patient #11 was listed under a pseudonym.
On 9/01/21 at

11:19 PM: "Patient arrived in ED"
11:21 PM: "Patient dismissed"

Emergency Medical Services (EMS) Report
Review of the receiving hospital [Hospital B] records on 10/8-9/21 identified the "John Doe" as Patient #11.

Review of the AFD "Patient Care Report", on 10/9/21, revealed "Patient #11 was picked up from the Anchorage Correctional Complex on 9/01/21. The EMS arrived on scene at 10:58 PM, transported the Patient at 11:13 PM, and arrived at the initial hospital at 11:20 PM. Arrived at Hospital B at 11:29 PM.

Review of the "Narrative" revealed:

"S [subjective]: This is a 73-year-old M with CC [current complaints] of chest pain, SOB [shortness of breath], and coughing blood. This Pt. [patient] States earlier today he began complaining of heavy chest pain in the middle of his chest radiating to his shoulder. He states mild SOB and that he coughed up a small about a blood. The Pt. Also states he was at the hospital earlier today and received multiple units of blood products for anemia. He was not admitted to the hospital and the corrections officer cannot verify the patient story. This Pt. is frequently transported by EMS for similar episodes. The Pt. denies N/ V, dizziness [illegible] symptoms. He has a history of HTN [high blood pressure], CVA [stroke], COPD [Chronic Obstructive Pulmonary Disease], diabetes, heart attack, anemia [low iron in the blood], and CRF [chronic kidney failure] ....
A [assessment]: chest pain
P [plan]: assessment, VS, loaded to stretcher to MICU [medical intensive care unit], transport code yellow status 3, repeat VS enroute. Pt. was transported to ARH ER. On arrival to ARH ER the staff met us at the ER MICU Bay stating they cannot accept the patient due to being on full closure. They advised us to transport the Pt. to [Hospital B] ER.

On arrival to [Hospital B] ER moved Pt. to triage. Pt. report at bedside to ER staff. PT. care transferred at that time without incident."
Review of the timeline revealed EMS arrived at the second destination with Patient #11 at 11:29 PM, 9 minutes after departing from ARH.

Hospital B Records

Review of the Patient #11's medical records from Hospital B on 10/06/21, revealed the Patient arrived at the ED on 2/01/21 at 11:33 PM.

Review of the "Emergency Department Record", performed at Hospital B on 9/02/21 revealed "[Patient #11] is a 73 yo male who presents with chest pain and shortness of breath. Patient states that around 7 PM tonight he started to have chest pressure on the left side of his chest like an elephant sitting on his chest. This is similar to a prior heart attack that he had many years ago. He has not had any worsening of the symptoms with exertion or movement of his arms. He has had numbness along his right upper shoulder and started having nausea and vomiting with blood- tinged vomit. He has had shortness of breath since that time as well. ... He was not seen by the medical staff at jail until 11:00 PM tonight he has been receiving his medications normally ...The most recent note in our system is from being seen in February 2021 for a left heart Cath [insertion of a catheter into the heart]. He did not have obvious chest pain due to coronary [heart] insufficiency and no evidence of spasm. They found mild CAD [coronary artery disease] in all vessels and only moderate disease at 50% in the diagonal vessel... Looking in care everywhere I do not see any lab test or other work up since June 2021 at Alaska Regional Hospital."

Interviews

During the entrance interview on 10/05/21 at 9:15 AM with the CEO, CMO, and Quality and Risk Manager, the CEO stated the facility learned of the event the next morning when they were contacted by the AFD. The CEO stated the facility immediately ensured all the staff were reeducated in EMTALA requirements and understood a patient presenting to the ED with the medical emergency had a right to a medical screening exam. Someone had responded to the EMS call and forgot to remind them the hospital was on a closure status (so the patient could go to the next available hospital). The Charge RN [LN #3] on that night had met the ambulance in the bay and had sent it on to the next hospital.

During an interview in the ED on 10/05/21 at 9:40 AM, ED Tech #1 stated when patients present to the ED, he/she will ask their name and why they are here. The ED Tech stated he/she also attempts to ask COVID screening questions prior to obtaining their vital signs. If the bays were open the patients were immediately brought back by the triage nurse.
Observations during the survey on 10/5/21 at 10:00 AM revealed the emergency calls came in via the call center located at the main nurses' desk in the ED.

During an interview on 10/05/2021 at 10:00 am, the Director of Emergency Services (DES) stated there are currently 20 relief, or travel, nurses from the lower 48 working within the facility. She further stated the orientation for these relief, or travel, nurses consisted of a HealthStream orientation (consisting of an array of topics), a check off high acuity nursing competencies, and one or two shadow shifts with a full time RN. The DES stated she was responsible for ensuring staff met the EMTALA requirements, triaging, nursing care, scheduling, quality assurance review, well as the supervision & administration of the unit including the integration of the department into the primary functions of the hospital.

During an interview on 10/06/21 at 10:00 AM, LN #1 stated when calls from EMS to the nurses' desk. The nurses respond and get the status of the patient. Nursing staff were also responsible letting EMS know if the hospital were on "closure" or "recovery," so EMS could route to next open hospital. If all the hospitals were "closed" the hospitals took turns taking patients. The LN stated the hospital had recently provided additional EMTALA education.

During an interview on 10/05/21 at 10:15 AM, LN #2 stated EMTALA training was done online by the HealthStream program, the LN stated he/she had recently completed education.

During an interview on 10/06/21 at 1:25 PM, the ED Medical Director stated he was aware of the EMTALA violation had a meeting with the medical staff regarding the event. He stated he planned to do more formalized education for physicians in the future.

During a second interview on 10/06/21 at 4:15 PM, the DES stated the AFD reached out to EMS Outreach Manager (LN #4) the next morning. The DES stated the medical team had audited the call that came in and reviewed the EMTALA event. The DES stated although LN #4 had documented on Patient #11, it was LN #3 that had met the ambulance in the bay.

Review of the facility policy "EMTALA Medical Screening Exam", approved 2/23/21, revealed "An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:
1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition; or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."

Review on 10/06/21 of the facilities. "Emergency Medical Treatment and active Labor Act [EMTALA], undated, the training provided to nursing staff, revealed Emergency Department Obligations Patient or representative request medical care. Hospital must provide medical screening exam."

Review of the reeducation on EMTALA requirements, provided to ED nursing and non-nursing staff, revealed all scheduled staff had completed the training by 9/07/21.
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