HospitalInspections.org

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Based on interview and record review, the facility failed to provide a Medical Screening Examination (MSE) for one individual (Patient #5) who presented to the Emergency Department (ED), with a police escort and under a Notice of Emergency Detention and Application for Examination, called a Title 47 (An Alaska Statue [AS], 47.30.705, which authorize the detention for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures), for assessment. This failed practice denied the individual an MSE, which violated the Emergency Medical Treatment and Labor Act (EMTALA), after it was requested on his/her behalf, in order to determine if stabilizing treatment was needed, or an appropriate transfer was required. Findings:

Patient #5

During an interview on 4/17/24 at 8:20 AM, Police Officer #1 stated in the early morning of 2/8/24, Patient #5 was arrested after trespassing at a homeowner's residence and was subsequently pepper sprayed by the homeowner. At the time of arrest, it was thought that Patient #5 had a warrant. Because Patient #5 was pepper sprayed and because of obvious untreated frostbite sores/wounds to both hands, Police Officer #1 took Patient #5 to the facility around 3:00 AM on 2/8/24 for a medical clearance prior to taking him/her to jail. Police Officer #1 drove his police vehicle into the facility's ambulance bay, which was a garage-like enclosure with garage-type roller doors, that was situated just off the ED.

Police Officer #1 further stated that while he/she was at the facility seeking treatment for Patient #5, it was determined that Patient #5 did not have a warrant. At that time, Police Officer #1 placed Patient #5 under a Title 47 for being gravely disabled.

Police Officer #1 stated Nurse #8 came into the ambulance bay and cleaned Patient #5's face of the pepper spray chemicals while Patient #5 sat in the back seat of the police vehicle. Police Officer #1 stated the nurse advised him/her that the facility was possibly on divert and their beds were full. After consulting with Anchorage Police Department (APD) dispatch, Police Officer #1 took Patient #5 to another hospital for treatment prior to an MSE being performed.

Review of Patient #5's "Notice of Emergency Detention and Application for Examination" (Title 47) form revealed: "Probable Cause: I certify that probable cause exists under AS 47.30.705 to believe that the above-named person is mentally ill and as a result of that condition is likely to cause serious harm to others of such an immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700. . . Information supporting probable cause. . . [he/she] was acting extremely erratic and uncontrollable. [Patient #5] appeared to have frostbite to both of [his/her] hands that were poorly care for. Given [Patient #5's] mental state [he/she] did not appear to have the ability to care for [his/her] injuries in addition to being not properly dressed for the weather. . ."

Facility Encounter on 2/8/24 at 3:00 AM

Record review on 4/15-16/24 revealed Patient #5 was not listed in the ED log of encounters, nor did he/she have an active medical record with his/her name or date of birth for 2/8/24.
Review of the facility's ED log, dated February 2024, revealed an encounter, dated 2/8/24 at 3:00 AM, however the name was a location, "Albertville, Uganda." Further review revealed the arrival method was "police" and the discharge disposition was documented as "left prior to med screening exam." Further review revealed no documentation for chief complaint, ED disposition, or ED discharge disposition.

Review of this "Albertville, Uganda" medical record, dated 2/8/24, revealed three nurse's notes:

- 2/8/24 at 3:02 AM: "Went to ambulance bay to look at patient and to speak with officer. Patient sitting in the back of vehicle. Officer asked if the ED was busy. I stated that "we are busy but then everyone was." Officer then stated he would find out who was next in rotation for the next title 47 patient. He then asked if I could clean patient's face. When I returned with supplies the officer stated that [a secondary hospital] was the next in line to receive the next title 47 patient. I asked if he was sure and he said "yes."

- 2/8/24 at 3:07 AM: "Patient had been pepper sprayed and police requested that [his/her] face be washed. Face cleaned with milk and rinsed with saline. Patient appeared more comfortable after cleaning."

- 2/8/24 at 3:08 AM: "Officer did not provide full name or date of birth as he intended to leave with patient to Providence [hospital] based on own preference."

Further review of this medical record revealed a birthdate of 2/8/99 (which would have indicated the patient was 25 years old). No other documentation was included in this medical record, no MSE was documented as being performed by a physician on 2/8/24.

During an interview on 4/16/24 at 12:46 PM, the Quality Director stated the facility completed an investigation after leadership was alerted to a potential EMTALA violation on 2/8/24. Through video camera recording review and interview it was determined an EMTALA violation had occurred, as care was rendered to a patient in the ambulance bay by a nurse, however no MSE was completed.

An observation on 4/16/24 at 1:15 PM, of the video camera recording of the ED ambulance bay, from 2/8/24 at 3:00 AM, revealed the following:

- 3:00 AM: Nurse #13 entered the ambulance bay and opened the roller door of the bay. Police Officer #1 drove his police vehicle into the ambulance bay. A second Police Officer was observed to walk into the ambulance bay. Nurse #13 closed the ambulance bay door. Nurse #13 was observed to talk to the Officers in the ambulance bay.

- 3:02:25 (hour, minute, second) AM: Nurse #13 was observed to leave the ambulance bay. The two Police Officers stood in the ambulance bay, outside of the police vehicle.

- 3:07:25 AM: Nurse #8 observed to enter the ambulance bay and talk with the Police Officers.

- 3:09:56 AM: Nurse #8 left the ambulance bay.

- 3:11:57 AM: Nurse #8 returned to the ambulance bay with supplies. Nurse #8 placed medical supplies on the hood of the police vehicle and donned gloves. Nurse #8 poured liquid onto a cloth.

- 3:13:50 AM: Nurse #8 approached the backseat of the police vehicle and was observed to reach into the vehicle with the cloth.

- 3:14:16 AM: Nurse #8 prepared a second cloth by pouring liquid onto it and then returned to the backseat of the police vehicle.

- 3:16:00 AM: Nurse #8 gathered supplies off the police vehicle.

- 3:16:26 AM: Nurse #8 left the ambulance bay. The second Police Officer left the ambulance bay.

- 3:16:40 AM: Police Officer #1 opened the ambulance bay.

- 3:17:21 AM: Police Officer #1 backed out of the ambulance bay and left the facility premises.

During an interview on 4/16/24 at 1:32 PM, Nurse #8 stated during his/her shift on 2/8/24 at around 3:00 AM the facility received a request from a Police Officer to open the ambulance bay door. Nurse #13 went into the ambulance bay and opened the doors. Nurse #8 stated he/she could hear screaming and yelling coming from the ambulance bay, so he/she went out there to investigate. Nurse #8 stated the Police Officer mentioned, "it looks like you are busy." Nurse #8 stated he/she responded that they were, but that everyone was busy everywhere. Nurse #8 stated the Police Officer stated he/she was going to call to see which hospital got the next "title" and asked if Nurse #8 would get something to clean off Patient #5's face. Nurse #8 stated when he/she returned to the ambulance bay the Police Officer stated that a secondary hospital was the next hospital to receive a "title" and he would be taking the patient there. Nurse #8 further stated that he/she rendered care to the patient by washing Patient #5's face with milk and rinsed with saline. When asked if Nurse #8 informed the ED physician that there was a patient in the ambulance bay, Nurse #8 stated no he/she had not. When asked if Nurse #8 was aware of the EMTALA obligation to provide individuals with an MSE when they come to the ED for care, Nurse #8 stated he/she was aware however, because the patient was in police custody, he/she thought the Police Officer had the autonomy to do whatever he/she wanted with the Patient.

When asked if Nurse #8 observed any wounds on the patient, Nurse #8 stated he/she did observe that Patient #5's had "old frostbite" skin peeling on fingers, however Patient #5's hands were cuffed behind him/her and did not get a clear view of the wounds.

When asked if the ED was open to receiving patients on 2/8/24 at 3:00 AM, Nurse #8 stated the ED was not closed to patients and was not on divert. When asked if the ED physician was available to see patients on 2/8/24 at 3:00 AM, Nurse #8 stated Physician #33 was available.

Nurse #8 further stated after the Police Officer left with Patient #5, he/she alerted his/her Charge Nurse of the encounter and it was at this time that Patient #5's information was logged into the ED log and the medical record documentation was made. Nurse #8 stated he/she never obtained Patient #5's name or date of birth, so they made up a location as a name and created a date of birth for the medical record documentation. When asked how this was determined, Nurse #8 stated they just chose a place and guessed at a birthdate for an approximate year of age.

During an interview on 4/6/24 at 2:02 PM, Nurse #13 stated that he/she was at lunch when he/she was asked to go into the ambulance bay to open the roller door for a Police Officer. Nurse #13 stated that once the officer was inside the ambulance bay, he/she conversed with the Police Officers and it was conveyed that Patient #5 had been pepper sprayed and they had brought Patient #5 to the ED to have his/her erratic behavior assessed, prior to and after being pepper sprayed. Nurse #13 stated he/she did not relay this information to nurses in the ED, and when he/she left the ambulance bay, he/she returned to his/her lunch break.

When asked if cleaning a patient's face of pepper spray was rendering care, Nurse #13 agreed this was rendering care. Nurse #13 stated it was a nursing role to prepare a patient for a physician's assessment and this would include removing pepper spray chemicals so a thorough assessment could be performed. Nurse #13 stated a patient should have been assessed by a physician after being pepper sprayed to rule out any eye, nose, or respiratory trauma associated with the chemical.

Review of the facility's "Reason for Diversion" log, dated 2/6/24 through 2/8/24, revealed the ED was not on diversion on 2/8/24 at 3:00 AM.

Secondary Facility Medical Record Review

Review of Patient #5's medical record at the secondary hospital, dated 2/8/24 at 3:42 AM, revealed Patient #5, who was 28 years old, received an MSE which revealed the need to admit the patient due to the following concerns:

- Frostbite injuries, bilateral hands
- History of polysubstance abuse, with acute intoxication, and agitation
- Acute kidney injury, rhabdomyolysis
- Hypertension
- Possible sepsis
- Positive antibody for hepatitis C
- Prophylaxis for DVT (deep vein thrombosis)

Patient #5 was admitted to the hospital on 2/8/24 and discharged on 3/2/24.

Policy Review

Review of the facility's policy "Hospital EMTALA Central Log," dated 9/2023, revealed: ". . . The hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination ("MSE") could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. . .The logs must contain at a minimum: the name of the individual, or adequate identification; the date and time of the individual's arrival; an emergency record number for the individual; the nature of the individual's complaint; the individual's disposition; whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired; the time of the individual's departure; and the individual's condition on departure. . ."

Review of the facility's policy "Hospital EMTALA Medical Screening Examination and Stabilization," dated 9/2023, 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 ... A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC [emergency medical condition] exists ... [to] an individual who has such a request made on his or her behalf ..."

Further review revealed: " ...Note: A hospital my deny access to individuals when it is in "official diversionary" status because it does not have the capability or capacity to accept any additional emergency individuals at the time. The hospital shall develop and adopt written criteria that describe the conditions under which any or all of the hospital's emergency services are deemed to be at maximum capacity. Caution: If the ambulance staff disregards the hospital's instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE ..."

Review of Alaska Statute (AS) 47.30.705(a) revealed: "A peace officer ... who has probable cause to believe that a person is gravely disabled or is suffering from mental illness and is likely to cause serious harm to self or others of such immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures set out in AS 47.30.700, may cause the person to be taken into custody by a peace officer ... and delivered to the nearest ... evaluation facility or treatment facility ..."
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