HospitalInspections.org

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Based on observation, record review, and interview, the facility failed to inform each patient of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible, for all patients in the Emergency Department (ED). This failed practice placed all patients of the ED (current census of 12) at risk for not knowing their patient rights, the grievance process, or how to contact outside resources for assistance if needed. Findings:

An observation on 1/12/24 at 9:10 AM, of the ED lobby revealed the "Notice of Privacy Practices," for medical records and patient information privacy, were posted. Further review revealed the patient rights were not posted anywhere in view.

Record review medical records for patients seen in the ED, from 9/2/23 to 12/27/23, revealed no documented acknowledgement of being informed of, or provided a copy of, the patient rights for 10 out of 10 records reviewed.

Record review of the facility's consent to treat form "Authorizations and Services Terms," dated 1/2022, revealed no documented acknowledgement of being informed of, or provided a copy of, the patient rights.

During an interview on 1/12/24 at 1:49 PM, the Accreditation Program Manager stated the "Authorizations and Services Terms" form was redrafted in late 2021, to replace older forms and consolidate them into one. The Accreditation Program Manager stated this form was used as a consent to treat and was used hospital-wide, for inpatients and outpatients. The Accreditation Program Manager further stated it was only discovered, during this survey, that the documented acknowledgement for the notice of patient rights was inadvertently dropped from the new form's verbiage when the redraft occurred.

Review of the facility's previous consent form "Consent for Health Care Services," dated 4/2018, revealed: " ... Acknowledgements: I acknowledge that I have been informed of ... "Patient Bill of Rights"/"Patient Rights and Responsibilities" ..."

During an interview on 1/12/24 at 4:43 PM, ED Receptionist #1 stated that when a patient comes into the ED, he/she takes the patient's name, date of birth, and why they had come to the ED. ED Receptionist #1 would then create a wrist band identifier and labels for patient paperwork. When asked if he/she offered patients the patient rights, ED Receptionist #1 stated he/she did not. When asked if he/she completed the "Authorizations and Services Terms" consent form, ED Receptionist #1 stated he/she did not, that this form was completed in the ED with Registration staff.

During an interview on 1/12/24 at 4:45 PM, Registration Representative #4 stated his/her role in the ED was to verify patient identification and completed ED consents and other paperwork. When asked if he/she offered patients the patient rights, Registration Representative #4 stated he/she did not.

An observation on 1/12/24 at 4:48 PM, revealed the facility's pamphlets of patient rights "Patient Rights [and] Responsibilities," dated 6/2019, were to the left of the ED receptionist desk, on a counter to the side of the desk that was lower and not visible from the front desk area. Further observation revealed the pamphlets were in a wire meshed file holder. The pamphlet's title was obscured by the wire mesh. There was no signage to indicate where the patient rights were located. There was no label on the file holder to indicate patient rights were stored here.

Review of the facility's policy "Patient Rights and Responsibilities," dated 11/10/22, revealed: " ... A framed copy of the "Patients' Rights and Responsibilities" statement is on display in multiple departments throughout the organization's facilities, in each Patient and Visitor Guide, is given to each patient at time of registration, and is placed in the pre-admission packets .... Notice of Rights. The hospital will inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible ..."
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Based on record review and interview, the facility failed to ensure that arrangements from a discharge plan evaluation were made for 1 patient (#16), out of 10 patients reviewed. Specifically, the facility failed to follow the physician's order from a discharge plan evaluation, which was to discharge Patient #16, who was intoxicated, directly to the Community Service Patrol (CSP - a service provided to take intoxicated or incapacitated people into protective custody to prevent victimization and cold-related injuries) for appropriate after care. This failed practice placed the patient at risk for the inability to care for himself/herself and exposure to cold weather which may have resulted in cold-related injuries, hypothermia, and/or death. Findings:

Record review on 1/12/24 revealed Patient #16 was seen in the ED on 12/3/23 at 4:50 PM for a fall and complaints of feeling shaky and weak. Further review revealed this patient had a long history of alcohol abuse and had been seen multiple times in the ED due to alcoholism, the last time being at 1:00 AM earlier in the day. Patient #16 had also recently tested positive for COVID and was required to wear a mask.

Review of Patient #16's ED assessment, dated 12/3/23 at 4:50 PM, revealed that at 5:00 PM his/her blood alcohol concentration (BAC - the metric used to measure the amount of alcohol in a person's bloodstream) was 0.411% (over 5 times the legal limit of 0.08%).

Review of the physician's notes, dated 12/3/23 at 5:49 PM, revealed: " ... We observe[d] the patient for 90 minutes in the emergency department. [His/Her] alcohol level is quite elevated at 411. Patient has a long history of alcohol abuse. [He/She] is ambulatory. We will call CSP and have [him/her] discharged to their care ..."

Review of Patient #16's "Emergency Department Report for ESP [Emergency Service Patrol, also called CSP - Community Service Patrol]/Detox or Fairbanks Correctional Center" form, signed by the Physician #7 on 12/3/23 at 5:56 PM, revealed: "Diagnostic Results: etoh [alcohol] 411 [at] [5:00 PM] ... 97.6 [degrees Fahrenheit] temp ... Functional Status at Discharge: Ambulatory, tolerates PO [fluid/food by mouth] ... I certify this patient is medically stable for transport ..."

During an interview on 1/12/24 at 4:30 PM, Physician #7 stated that when an intoxicated individual presented to the ED, they were assessed and then evaluated until deemed stable, which could take hours. A patient would be deemed stable to discharge once they were ambulatory. Physician #7 stated CSP would be part of the discharge plan evaluation when the hospital wanted to ensure an intoxicated patient had a safe placed to discharge to.

Review of a nurse's note, dated 12/3/23 at 5:42 PM, revealed: "Pt [patient] out of bed several times, bed alarm placed at arrival. Self discontinued prehospital IV [intravenous catheter for intravenous fluids] to right FA [forearm]. Dressed self, demanding discharge. Able to put on own boots, ambulating around room. Call to FPD [Fairbanks Police Department] for CSP transport, several calls prior. Pt discharged to lobby." Further review revealed an addendum was added at 6:05 PM: "pt to FMH [Fairbanks Memorial Hospital] lobby with steady gait. Given ED form for CSP transport."

Review of the facility's video recording, of the ED lobby on 12/3/23, revealed:

5:52 PM - Patient #16 observed to walk independently from ED Room 15 to the ED lobby with ED nurse. Patient #16 observed to walk to a lobby phone and make a phone call.

6:03 PM - A security guard was observed to talk to Patient #16, then point in the direction of the entrance/exit door of the ED lobby. Patient #16 was observed to leave the ED after this, walk across the ED parking lot and cross the street. Patient #16 was observed to walk down a street until he/she was no longer viewable from the camera.

6:38 PM - CSP van was observed to park in the ED parking lot. CSP employee entered the ED and walked to the ED nurse's station to speak to staff.

6:42 PM - CSP employee walked into the lobby and talked to security. Then CSP employee left and drove away.

During an interview on 1/12/24 at 5:05 PM, the Plant Operations and Safety Director stated he was able to play the audio of the 12/3/23 video recording from when the security guard interacted with Patient #16 in the ED lobby. Per the Plan Operations and Safety Director, the security guard informed Patient #16 that he/she had been asked to keep his/her mask in place while in the ED area three times. Since Patient #16 would not comply with this request, Patient #16 needed to leave the ED lobby.

During an interview on 1/12/24 at 5:20 PM, the ED Director stated that it was not normal protocol to discharge an intoxicated patient, who was waiting for CSP transport, to the ED lobby. The ED Director stated the normal protocol would have been to have the patient wait in the ED until CSP arrived. CSP would enter the ED, come to the ED nurse's desk and receive a report. The ED staff would then hand off the patient to the CSP employee for transport. The ED Director further stated she could not explain why the ED Nurse chose to discharge Patient #16 to the ED lobby on 12/3/23.

Record review of the AK #4465 intake documents, dated 12/4/24, revealed that at 11:00 PM on 12/3/23 Patient #16 was found by FPD laying outside on a sidewalk near a facility that was across the street from FMH. Patient #16 was unable to ambulate independently and could barely shuffle without assistance. It was -9 degrees outside. FPD attempted to take Patient #16 to a sleep-off/detox facility, however they would not accept him/her due to his/her intoxicated state. FPD then took Patient #16 to Fairbanks Correctional Center (FCC) for assessment. At 11:00 PM, Patient #16's BAC was 0.216%. Patient #16 was taken back to the ED for treatment.

Review of Patient #16's "ED Triage," dated 12/3/23 at 11:55 PM, revealed: " ...FPD picked up from outside, denied from FCC [Fairbanks Correctional Center] for inability to ambulate and intoxicated mentation ..." Further review revealed Patient #16's temperature was 96.8 degrees Fahrenheit. Further review revealed no Physician's note was present in Patient #16's medical record from this visit.

Review of the facility's policy "Emergency Department Patient Standards of Care," dated 7/11/23, revealed: " ...Medical care is directed by the ED medical provider/designee ... Discharge. The ED Provider and/or the licensed nurse is responsible for delivering discharge instructions to the patient ... Report is given to the receiving facility or unit using SBAR [Situation, Background, Assessment, Recommendation charting] format. Patient leaves Against Medical Advice (AMA) - Patient has received medical screening exam and has refused recommended treatment. The provider is notified of the patient's desire to leave against medial advice. Attempts are made to ascertain the reason the patient wants to leave and intervention is performed as appropriate. If the patient still desires to leave, the AMA form is signed and witnessed ... Handoff Communications: The transition of the patient ("hand off" of patient care) is communicated using SBAR, including an opportunity to ask and respond to questions from all involved parties ..."

Review of information from American Addictions Centers Alcohol.org at https://alcohol.org/health-effects/blood-alcohol-concentration/ , "Blood Alcohol Concentration Levels and How They Affect the Body, dated 3/27/23, revealed: " ... Although there is no one universally accepted standard for what is considered a "safe" level of drinking, the metric used to measure the amount of alcohol in a person's bloodstream is called blood alcohol concentration, or BAC. Common symptoms, levels of impairment, and risks of various blood alcohol concentration (BAC) levels include ... 0.20 - 0.29%: Confusion, feeling dazed, and disorientation are common. Sensations of pain will change, so if you fall and seriously hurt yourself, you may not notice, and you are less likely to do anything about it ... 0.30 - 0.39%: At this point, you may be unconscious and your potential for death increases ... 0.40% and over: This level of BAC may put you in a coma or cause sudden death because your heart or breathing will suddenly stop. This is what is known as a lethal blood alcohol level ..."
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