HospitalInspections.org

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Based on record review and interviews the facility failed to ensure the hospital met the Condition of Participation for Patient Rights. The hospital failed to assure patient representative's rights were protected and promoted. Due to the severity of deficient practice at CFR 482.13(b)(2), an immediate jeopardy occurred under CFR 482.13 Patient Rights.

Findings:

A-0131 - Patient Right: Right to informed decisions regarding care: The facility failed to:

1) Notify legal guardians when patients were evaluated in the emergency department (ED) to provide consent for treatment, as well as, be consulted regarding treatments and/or medications provided to the patient's during care;

2) Have a system in place to alert staff, or make it possible to easily view within the electronic health record (EHR), of legal guardian status for patients;

3) Address a suicide attempt during a BURT (Behavioral Urgent Response Team) assessment for suicidal ideation;

4) Ensure accurate guardian and suicide attempt history information was consistently presented in all BURT assessments;

5) Ensure the patient's EHR contact information was up to date to reflect the correct legal guardian and caregiver; and

6) Ensure a physician's order for a BURT consult was completed prior to discharge of a patient with disorganized thoughts.

These failed practices constituted an immediate jeopardy to Patient #5's health and safety and had the potential of harm for all patients with legal guardians or medical power of attorney. This situation was brought to the attention of the facility's administration on February 26, 2019 at 4:30 pm, at which time the facility was notified of the deficient practice and high risk to patients.

The immediacy was removed by the facility by February 27, 2019 at 8:10 am.
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Based on record review and interview the facility failed to allow 4 patient representatives, (#s 5, 4, 9, and 10), out of 4 sampled patients with legal guardians, the right to make decisions about treatment plans and discharges from the emergency department (ED) which placed the patients in immediate jeopardy for serious harm and/or death. Specifically, the facility failed to:

1) Notify legal guardians when patients are evaluated in the ED to provide consent for treatment, as well as, be consulted regarding treatments and/or medications provided to the patient's during care;

2) Have a system in place to alert staff, or make it possible to easily view within the electronic health record (EHR), of legal guardian status for patients;

3) Address a suicide attempt during a BURT (Behavioral Urgent Response Team) assessment for suicidal ideation;

4) Ensure accurate guardian and suicide attempt history information is consistently presented in all BURT assessments;

5) Ensure the patient's EHR contact information is up to date to reflect the correct legal guardian and caregiver; and

6) Ensure a physician's order for a BURT consult was completed prior to discharge of a patient with disorganized thoughts.

This failed practice resulted in harm for 1 patient (#5), (an incapacitated individual with a proven history of multiple suicide attempts/gestures) when ED-provided medication was used in a suicide attempt, and had the potential of harm for all patients with legal guardians or medical power of attorney. Findings:

This situation was brought to the attention of the facility's administration on February 26, 2019 at 4:30 pm, at which time the facility was notified of the deficient practice and high risk to patients. The immediacy was removed by the facility by February 27, 2019 at 8:10 am.

Patient #5

Record review on 2/25-28/19, 3/1/19, and 3/4/19 revealed Patient #5 had an active diagnosis list within Alaska Native Medical Center (ANMC) records that included chronic depression, borderline personality disorder (a mental disorder characterized by unstable moods, behavior, and relationships), and mental retardation, mild, IQ (intelligence quotient) 50-70 (below-average intelligence or mental ability and a lack of social skills necessary for day-to-day living).

On 1/30/19, Patient #5 presented to the ED with his/her Assisted Living Facility (ALF) Staff #1 for suicidal thoughts. The "ED Triage Note/Assessment," dated 1/30/18 at 6:26 pm, documented Patient #5 had indicated 'I'm going to do something real stupid to myself' and ALF Staff #1 reported the Patient 'jumped out of car on the way to the ED.' ALF Staff #1 had to return to the ALF after the Patient was taken into the ED for assessment.

Review of Patient #5's medical record revealed an "ED Note-Provider," dated 1/30/19 at 9:33 pm, which documented that Patient #5 had "abnormal/psychotic thoughts: suicidal" and requested a BURT consult to assess the Patient for safety.

In conjunction with this BURT consult, the provider also performed a physical examination which revealed right lower quadrant abdominal pain, left ear pain, and shortness of breath. These symptoms were treated through diagnostic testing; albuterol nebulizer breathing treatments (liquid albuterol that is turned into a mist. It is inhaled to open lung passages); Intravenous (IV) fluid; and Tylenol for pain.

Further review of Patient #5's medical record revealed a "BURT Consult," dated 1/30/19 at 10:26 pm, which documented the Patient had a "long history of cutting and other suicidal gestures without intent." After talking with the Patient, BURT Staff #1 documented the Patient's presenting risk was "low" and documented his/her impression of Patient's "Stages of Change" was "precontemplation." (Boston University School of Public Health [www.sphweb.bumc.bu.edu]: A Behavioral Change Model: Precontemplation: People are often unaware that their behavior is problematic or produces negative consequences).

It was noted during the review that BURT Staff #1 documented Patient #5's suicide attempt, "attempted to jump from car on the way here," but did not directly assess and/or rule out this gesture within his/her consult.

BURT Staff #1 further documented the patient made "chronic suicidal statements without plan or intent" and cleared the Patient to return home to the ALF via taxi when he/she was medically cleared.

Additional review of the "ED Note-Provider," dated 1/30/19 at 9:33 pm, revealed Patient #5 was diagnosed with suicidal ideation. The documentation revealed: "We discussed that patient should take Tylenol as needed for pain and this was prescribed. I also prescribed Bentyl [medication to treat abdominal pain] as needed for abdominal pain....Just after discussing discharge patient stated [he/she] was again suicidal and would hang [himself/herself] if [he/she] was discharged back to the ALF. I discussed the patient with BURT again...BURT saw [him/her] again and indicated [he/she] was no longer suicidal and is cleared for discharge. Patient was discharged back to [his/her] ALF, transported there via taxi voucher."

Review of the "Inactive Medication Orders" revealed the hospital dispensed 40 tablets of Tylenol 325mg and 9 tablets of Bentyl 20mg to the Patient on 1/31/19 at 3:10 am. Patient #5 was discharged on 1/31/19 at 5:44 am from the facility in a taxi, alone, with these medication.

During a telephone interview on 2/26/19 at 1:10 pm, ALF Supervisor #1 stated Patient #5 had resided at the ALF for over 8 years. He/she described Patient #5's intellectual functioning as poor; he/she had poor judgement and makes poor decisions. Patient #5 requires constant monitoring and would not care for himself/herself if not supervised. ALF Supervisor #1 stated he/she was never contacted by the provider or nurse from ANMC to go over what occurred during the ED visit. The ALF staff were unaware Patient #5 was returning from the ED or that he/she had returned with medication.

During a telephone interview on 2/26/19 at 2:25 pm, ASSETS Staff #1 (a contracted individual who is employed with "Alaska Specialized Employment and Training Services" [Assets, Inc.] to help Alaskans with disabilities live independently, form friendships, and find good jobs), who was working with Patient #5 during the day, stated that around 1:00 pm, the Patient reported to him/her that at 7:00 am, after returning from the ED, he/she had ingested all the Tylenol and Bentyl medication provided to him/her during the ED visit in an attempt to kill himself/herself. The Patient had given the ASSETS Staff the empty pill bottles. ASSETS Staff #1 reported this to the ALF and took Patient #5 to Providence Hospital for evaluation.

Review of the Providence Hospital "Emergency Department Encounter," dated 1/31/19 at 1:43 pm, revealed documentation that Patient #5 had an elevated Tylenol blood level of 76 mcg/mL (University of Rochester Medical Center [www.urmc.rochester.edu]: 10 -20 mcg/mL is considered the safe range). The Provider's final impression was that Patient #5 made a suicide attempt by an intentional Tylenol overdose and was admitted to the hospital for observation.

Continued interview with ALF Supervisor #1 revealed Patient #5 had an Office of Public Advocacy (OPA) guardian. This guardian has full guardianship and maintained all medical decision-making power for Patient #5. ALF supervisor #1 stated the ANMC "picks and chooses as to when they make the guardian sign medical paperwork."

During an interview on 2/26/19 at 2:05 pm, the ANMC Manager of Accreditation stated a review of Patient #5's entire medical record (hard chart and EHR - electronic health record) revealed no guardianship documents. He/she further stated the "Patient Registration Sheet" (a demographic sheet which includes patient information, insurance, emergency contact, ethnicity, native blood quantum, and guardianship information) was never completed for Patient #5.

Patient #5's EHR does list the OPA guardian's name in the contact person section, however there is no identification with the name to indicate they are a legal guardian.

During a telephone interview on 2/26/19 at 1:35 pm, OPA Guardian #1 stated he/she has been Patient #5's guardian since 2008 and the Patient required 24/7 staff supervision or "[he/she] would die." He/she was shocked that Patient #5 was allowed to leave ANMC ED with medications due to his/her history of medication overdoses. He/she also stated ANMC had contacted him/her in the past and does not understand why they would not have the guardianship paperwork in the Patient's medical record.

OPA Guardian #1 stated ANMC did not contact him/her about the 1/30/19 ED visit, treatment rendered, or the discharge orders/dispensed medications. OPA Guardian #1 further stated that Patient #5 should not be signing any consent forms, to include discharge instructions.

Review of the guardianship paperwork, "Findings and Order of Guardianship," dated 2/2/09 (which the facility had faxed to them during the course of this survey), revealed: "It has been shown by clear and convincing evidence that the respondent is incapacitated...The respondent is totally without capacity to care for [himself/herself]...therefore, the court will appoint a full guardian. The appointment of a guardian is necessary to provide for the needs of the respondent including: medical care, any mental health treatment that is necessary...physical and mental examinations necessary to determine the ward's medical and mental health treatment needs."

Further review revealed: "The guardian's powers and duties include the power to approve administrations of any and all medication to be prescribed for the respondent, and to approve medical procedures..."

During the record review of the 1/30/19 ED encounter, it was noted Patient #5 was considered not able to sign the "Authorization for Emergency Treatment," due to "[patient] unable [suicidal ideation]." Patient did sign consent for a CT scan of his/her abdomen and did sign the discharge statement which included the prescription medication explanation of the Tylenol and Bentyl dispensed to him/her.

During an interview on 2/27/19 at 6:20 am, BURT Staff #1 stated asking about guardianship is not a consistent question asked during BURT consults. He/she stated he/she would include the guardian in the decision making for a patient if their chart indicated the patient had a guardian. BURT Staff #1 further stated the EHR does not automatically alert staff if a patient has a guardian. During the 1/30/19 ED BURT consult for Patient #5, BURT Staff #1 stated he/she did not think about guardianship or ask this question during the course of this consult.

BURT Staff #1 had stated he/she had known Patient #5 for years. He/she stated he/she would not have recommend handing Patient #5 a bottle of medication. He/she stated Patient #5 was not responsible enough to give them to ALF staff upon his/her return. This type of information was not conveyed to the ED Provider at the time the BURT consult was discussed.

Review of all ED documentation for 1/30-31/19 for Patient #5 revealed there was no documentation within the "ED Note-Provider," dated 1/30/19 at 9:33 pm; "ED Note-Nursing," dated 1/31/19 at 5:38 am; or "BURT Consult," dated 1/31/19 at 5:50 am, that the ALF and/or guardian was contacted about Patient #5's discharge from ED, what treatment was rendered, or that Patient #5 was given medication.

Additional review of Patient #5's medical record revealed eight "BURT consults;" two "Behavioral Health Notes;" two "General Notes;" and one "BURT SOAP" note since 3/1/18. Of this documentation, Patient #5's OPA guardian was mentioned six times (3/1/18; 3/3/18; 3/5/18; 3/8/18; 4/13/18; and 5/21/18) and Patient #5's history of attempted overdosing three times (3/3/18; 3/5/18; and 5/21/18).

This information was not forwarded into the 1/30/19 or 1/31/19 BURT consults completed by BURT staff #1.

Review of Patient #5's demographic sheet provided by ANMC revealed the legal guardian was listed as the emergency contact and the Patient's ALF caregiver as "next of kin." Patient #5 was listed as his/her guarantor.


Patient #4

Record review on 2/25-28/19, 3/1/19, and 3/4/19 revealed Patient #4 had an active diagnosis list within ANMC records that included schizoaffective disorder, bipolar type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).

On 11/1/18, Patient #4 presented self to the ED with disorganized thoughts. The "ED Note-Provider," dated 11/1/18 at 1:50 pm, documented the Patient reported he/she was just discharged from Providence Hospital. He/she reports he/she had been off his/her medication and has not been able to get to the psychiatric clinic.

Review of Patient #4's medical record revealed an "ED Triage Note/Assessments," dated 11/1/18 at 1:39 pm, revealed: "Nursing Narrative Details: states was just discharged from Providence, 'they sent me back to that serial rapist's house with a taxi voucher. I'm not going back there, I need to go into witness protection.' "

Further review of the "ED Note-Provider," dated 11/1/18 at 1:50 pm, revealed an impression of "suicide ideation" and "Schizo affective schizophrenia" (documented with code "ICD10-CM F25.0." ICD-Data base [icd10data.com]: this code was identified as schizoaffective disorder, bipolar type) and documented: "Patient with disorganized thoughts. [He/she] has not been taking any of [his/her] medications. Does not have a specific suicide plan and felt not to meet criteria. Patient amenable to taking [his/her] medications. Patient was seen by BURT invert prescription providers. Patient given home meds...After getting medications patient reported feeling better. Deemed stable for discharge."

Further record review revealed no documentation from the BURT provider.

During an interview on 2/26/19 at 10:20 am, the ANMC Senior Clinical Informaticist stated the BURT documentation from 11/1/18 was not in Patient #4's EHR. He/she did confirm it was mentioned in the provider note, but it was not found in the EHR.

Review of the "Summary of Care" for Patient #4's 11/1/18 ED visit revealed an OPA guardian's name in the emergency contact person section.

During an interview on 2/26/19 at 11:00 am, the Clinical Nurse Manager (CNM) for ANMC ED stated no guardian or OPA information comes up in the EHR when staff in the ED open Patient #4's chart.

During a second interview on 2/26/19 at 11:40 am, the CNM for ANMC ED stated the 11/1/18 BURT assessment summary for Patient #4 was not within the EHR system. He/she could not locate this document.

In addition, review of the record revealed an order for a BURT consult (see "Consult to Behavioral Urgent Response Team Inpatient" order, dated 11/1/18 at 1:43 pm) that did not occur. It is documented the order was "discontinued on 11/4/18 at 9:04 pm due to discharge."

Review of Patient #4's guardianship paperwork provided by ANMC, "Findings and Order of Guardianship," dated 2/16/07, revealed: "It has been shown by clear and convincing evidence that the respondent is incapacitated...The respondent is totally without capacity to care for [himself/herself]...therefore, the court will appoint a full guardian. The appointment of a guardian is necessary to provide for the needs of the respondent including: medical care, any mental health treatment that is necessary...physical and mental examinations necessary to determine the ward's medical and mental health treatment needs."

Further review revealed: "The guardian's powers and duties include the power to approve administrations of any and all medication to be prescribed for the respondent, and to approve medical procedures and administration of psychotropic medication."

During a telephone interview on 2/26/19 at 3:30 pm, OPA Guardian #2 stated Patient #4 lived in an ALF, a unit managed apartment. OPA Guardian #2 stated he/she does not always get calls from ANMC ED when the Patient is rendered care. Ideally, he/she would expect a call from the ED to request consent to treat and then be included in the plan for discharge prior to the Patient leaving the ED.

OPA Guardian #2 further stated that ANMC did not contact him/her about the 11/1/18 ED visit, treatment rendered, or the discharge orders/dispensed medications. OPA Guardian #2 also stated that Patient #4 should not be signing any consent forms, to include discharge instructions.

Additional review the "Summary Care" for Patient #4's 11/1/18 ED visit revealed a "Discharge Instructions" note which documented: "... [OPA Guardian #2] is aware of your visit and recommendations. [He/she] will pursue other housing options for you if needed..."

Review of a nursing notation, dated 11/1/19 at 4:24 pm, revealed: "Nursing Narrative Details: [vital signs] stable. Verbalized understanding of discharge instructions given along with 2 bus tokens. Meal to go given. Ambulatory with steady gait."

Review of the "ED Patient Summary," dated 11/1/18 at 4:29 pm, revealed a discharge statement page which included the prescription medication explanation for four tablets of Depakote (a medication used to help treat seizures and bipolar disorder) 250mg and 4 tablets of Zyprexa (an antipsychotic used to treat mental disorders, including schizophrenia and bipolar) 20mg that was dispensed to the Patient upon discharge.

During the record review of the 11/1/18 ED encounter, it was noted Patient #4 was considered not able to sign the "Authorization for Emergency Treatment," due to "[patient] condition." Patient did sign the discharge statement, however this statement did not include the medications dispensed to the Patient at discharge. Patient #5 was discharged on 11/1/18 at 4:29 am, from the facility with this medication.

Patient #9

Record review on 2/25-28/19, 3/1/19, and 3/4/19 revealed Patient #9 had an active diagnosis list within ANMC records that included a history of paranoid schizophrenia (a chronic mental illness; individuals with paranoid schizophrenia hold untrue beliefs [delusions] or hear things others don't hear [auditory hallucinations]) and noncompliance with medication treatment due to difficulty with route of medication administration.

On 2/19/19, Patient #9 presented to the ED with his/her ALF Staff #2, who requested an administration of medication. The "ED Triage Note/Assessment," dated 2/19/19 at 7:50 pm, documented ALF Staff #2 reported Patient #9 had missed his/her "mental health shot." ALF Staff #2 reported the Patient had been without oral Haldol (an antipsychotic/psychotropic medication) for 2 days and it had been 2 weeks and 2 days since the Patient's last Haldol shot. ALF Staff #2 reported the Patient has been noncompliant with attending scheduled appointments with his/her primary care provider and requested the Haldol shot to be administered through the ED.

Review of Patient #9's medical record revealed an "ED Note-Provider," dated 2/19/19 at 8:40 pm, which documented: "Patient's caregiver verbalized that ED had given permission to return to Fast Track/ED [a non-emergent level of care treatment area] as needed for biweekly injections if patient is non-compliant with medication [mgmt. - management] appointments. However, recommended that ALF staff try to continue to have patient see [PCP - primary care provider] and receive preventative and medication [mgmt. - management] visits through primary care."

Review of the "ED Triage and Assessment Adult - Text," dated 2/19/19 at 8:13 pm, revealed: "Nursing Narrative Details: [patient] stated [he/she] is not sure why [he/she] is here, not know what medication [he/she] is taking, does not know if [he/she] takes injection shots or medications. [patient] denies any pain."

Review of the "Inactive medication Orders" revealed Haldol Decanoate (a concentrated liquid Haldol with a longer duration of effect in the body; administered by shot) injection of 100mg was administered via injection on 2/19/19 at 8:46 pm.

Patient #9's EHR does list the OPA guardian's name in the contact person section, however there was no identification with the name to indicate they are a legal guardian.

Review of Patient #9's guardianship paperwork provided by ANMC, "Findings and Order of Guardianship," dated 2/4/09, revealed: "It has been shown by clear and convincing evidence that the respondent is incapacitated...The respondent is totally without capacity to care for [himself/herself]. The respondent has been diagnosed with a mental illness and has been hospitalized numerous times. [He/she] consistently does not take her prescribed medications. The respondent's thinking is disorganized and she does not have the ability to maintain [himself/herself]...therefore, the court will appoint a full guardian. The appointment of a guardian is necessary to provide for the needs of the respondent including: medical care, any mental health treatment that is necessary...physical and mental examinations necessary to determine the ward's medical and mental health treatment needs."

Further review revealed: "The guardian's powers and duties include the power to approve administrations of any and all medication to be prescribed for the respondent, and to approve medical procedures and administration of psychotropic medication."

During the record review of the 2/19/19 ED encounter, it was noted Patient #9 signed the "Authorization for Emergency Treatment" form for care. Further review revealed Patient #9 left without signing the discharge information sheet. The "ED Clinical Summary," dated 2/19/19 at 9:38 pm, documented Patient #9 left against medical advice at 9:38 pm.

Review of Patient #9's demographic sheet provided by ANMC revealed no one was listed for an emergency contact, labeled as "unknown," and the Patient's ALF caregiver as "next of kin." Patient #9 was listed as his/her guarantor.

During a telephone interview on 3/6/19 at 1:08 pm, the OPA Guardian #3 stated he/she took over Patient #9's guardianship on 9/1/16 and the information in the ANMC data base is not up to date. He/she described Patient's judgement as very poor, having no insight into his/her care. The Patient had a lengthy history of being noncompliant with his/her psychotropic medication treatment. He/she also stated ANMC had been very inconsistent with including him/her the Patient's care.

The OPA Guardian #3 further stated ANMC did not contact him/her about the 2/19/19 ED visit, treatment rendered, or the medication administered. It would be the OPA's expectation that he/she would be contacted at each ANMC encounter when services are rendered. He/she stated Patient #9 should not be signing any consent forms for treatment.

During the telephone interview the OPA Guardian #3 also identified that the next of kin ANMC had listed is not up to date. The new caregiver took over Patient #9's care in October of 2018.

Review of all ED documentation for 2/19/19 for Patient #9 revealed there was no documentation within the "ED Note-Provider," dated 2/19/19 at 8:40 pm, or the "ED Triage and Assessment Adult - Text," dated 2/19/19 at 8:13 pm, that the guardian was contacted about Patient #9's admit to or discharge from ED or what treatment, to include medication, was rendered.

Patient #10

Record review on 2/25-28/19, 3/1/19, and 3/4/19 revealed Patient #10 had an active diagnosis list within ANMC records that included mental disability (a wide range of conditions that affect mood, thinking, and behavior), mood disorder (a group of mental health disorders that affect emotional state) and PTSD (Post Traumatic Stress Disorder: anxiety and flashbacks triggered by a traumatic event).

ED Encounter #1

On 2/21/19, Patient #10 presented self to the ED due to burning urination and requested an sexually transmitted disease (STD) check.

Review of Patient #10's medical record revealed an "ED Note-Provider," dated 2/21/19 at 7:44 am, which documented: "The patient presents Patient requests STD screen. [He/she] think [he/she] may have been exposed to an STD from [his/her] ex. Feels like UTI [urinary tract infection]...Treating for UTI as symptoms consistent with prior UTIs."

Further review revealed the provider completed an STD screening and diagnosed dysuria (pain or burning when urinating). The provider prescribed an antibiotic, Macrobid 100mg oral capsule twice a day for 5 days.

Review of the "Inactive Medication Orders" revealed the hospital dispensed 10 capsules of Macrobid 100mg to the Patient on 2/21/19 at 8:36 am. Review of the "Rx AMB PHR Medication Teaching" documentation, dated 2/21/19 at 8:52 am, revealed a pharmacist provided Patient #10 with medication education for the Macrobid.

Patient #10's EHR does not list the OPA guardian's name in the contact person section.

Review of the guardianship paperwork found in Patient #10's record, "Findings and Order of Guardianship," dated 2/4/09, revealed: "It has been shown by clear and convincing evidence that the respondent is incapacitated...The respondent is totally without capacity to care for [himself/herself]...therefore, the court will appoint a full guardian. The appointment of a guardian is necessary to provide for the needs of the respondent including: medical care, any mental health treatment that is necessary...physical and mental examinations necessary to determine the ward's medical and mental health treatment needs."

Further review revealed: "The guardian's powers and duties include the power to approve administrations of any and all medication to be prescribed for the respondent, and to approve medical procedures and administration of psychotropic medication."

During the record review of the 2/19/19 ED encounter, it was noted Patient #10 signed the "Authorization for Emergency Treatment" form for care and the discharge statement which included the prescription medication explanation of the Macrobid provided to him/her.

Review of Patient #10's demographic sheet provided by ANMC revealed a life partner was listed for an emergency contact and a relative of the Patient as "next of kin." Patient #10 was listed as his/her guarantor.

Review of all ED documentation for 2/21/19 for Patient #10 revealed there was no documentation within the "ED Note-Provider," dated 2/21/19 at 7:44 am or the "Rx AMB PHR Medication Teaching" documentation, dated 2/21/19 at 8:52 am, that the guardian was contacted about Patient #10's admit to or discharge from ED, what treatment was rendered, or that Patient #10 was given medication.

ED Encounter #2

On 2/22/19, Patient #10 was brought to the ED by police for unsafe behavior. The "ED Note-Provider," dated 2/22/19 at 3:11 am, documented Patient #10 reported feeling "stressed" and "sad." He/she stated he/she was "thinking crazy" and further clarified this as having thoughts of harming himself/herself.

A "Notice of Emergency Detention and Application for Evaluation" was completed by the ED provider and a "Notice of Rights upon Emergency Detention" was provided to the Patient, who signed this on 2/22/19 at 3:00 am. There was no documentation on either of these forms to indicate they attempted to contact the legal guardian for the Patient. The provider also ordered a BURT consult to assess Patient #10's safety.

Review of Patient #10's medical record revealed a "BURT Consult," dated 2/22/19 at 6:08 am, which documented the Patient had "...multiple admissions as an adolescent to North Star Hospital, Alaska Psychiatric Institute (API), Booth Memorial, and Providence Discovery." After talking with the Patient, BURT Staff #2 documented the Patient's presenting risk was "low" and documented his/her impression of Patient's "Stages of Change" was "precontemplation."

BURT Staff #2 further documented: "...The patient reluctantly participated in the assessment after several tries, and softly mumbled answers that were virtually unintelligible. He/She punctuated his/her soft speech by loudly stating he/she no longer endorsed suicidal ideation. The patient does not meet criteria for involuntary hospitalization...In consultation with the attending physician, it is recommended that the patient be discharged with a bus pass to go to Gospel Rescue Mission for breakfast."

Further review of Patient #10's medical record revealed an "ED Note-Provider," dated 2/22/19 at 3:11 am, revealed the provider diagnosed the Patient with "psychiatric problem" and documented: "Patient is feeling much better, patient has been seen by behavioral health who agrees that he/she no longer seems to present an acute threat to [himself/herself] or others, recommends discharge home, patient is comfortable with this plan."

Review of the "ED Note-Nursing," dated 2/22/19 at 6:10 am, revealed a discharge nursing note: "Nursing Narrative Details: Reviewed [DC - discharge] instructions, safety, community resources and when to return. Patient verbalized understanding but refused DC vital signs. Patient given bus pass and a glass of water to go."

Review of Patient #10's medical record revealed no discharge information sheet could be located for this 2/22/19 ED encounter.

Review of all ED documentation for 2/22/19 for Patient #10 revealed there was no documentation within the "ED Note-Provider," dated 2/22/19 at 3:11 am; "ED Note-Nursing," dated 2/22/19 at 6:10 am; or "BURT Consult," dated 2/22/19 6:08 am, that the guardian was contacted about Patient #10's admission under emergency detention status or his/her discharge from the ED, what treatment was rendered, or recommendations for follow up.

During a telephone interview on 3/11/19 at 8:35 am, OPA Guardian #4 stated the ANMC guardian information was not up to date as Patient #10's case was transferred to OPA Guardian #5 on 12/21/18. OPA Guardian #4 described Patient #10's judgement as very poor; having no insight or judgement into being able to care for himself/herself. Patient #10 is not able to be relied on to follow instructions provided by doctors and therefore should not be signing any consents, discharge instructions, or be given any medication to independently take correctly. OPA Guardian #4 further stated any medication should be given to the ALF staff where he/she resides to make sure the Patient gets it as ordered.

During a telephone interview on 3/11/19 at 8:50 am, OPA Guardian #5 stated ANMC did not contact him/her about the 2/21/19 or 2/22/19 ED visits for Patient #10. He/she stated his/her expectation would be for ANMC to contact him/her for consents and approval of medications. He/she stated medications should be provided to the ALF staff for proper dispensing and to ensure the Patient takes them as directed. OPA Guardian #5 further stated he/she would definitely want to be aware of any emergency detentions that occur and should be contacted to be involved in Patient #10's care decisions.

During an interview on 2/26/19 at 9:55 am, the ANMC Director of Patient Registration stated the role of the registration personnel for ANMC ED visits or admissions is to update demographic information, ask for identification and insurance information. He/she stated it is not asked if a patient has a legal guardian when they are registered for the ED or inpatient units.

The ANMC Director of Patient Registration further stated that ANMC relies on the patient to tell the registration personnel, during ED visits or admissions, if they have a legal guardian. Additionally, he/she also stated he/she understands patients who have a legal guardian may not have the capacity to state they have a legal guardian. He/she agreed this was a system failure within ANMC. He/she further stated that when a patient is registered for the first time into ANMC a "Patient Registration Sheet" is completely filled out and if a patient has a guardian, the paperwork should be brought into ANMC to be uploaded into the system. It is the responsibility of Registration to upload this information into the EHR. The Director of Patient Registrations also stated the Patient Registration Sheet is never completely filled out again, nor is it ever updated. This "Patient Registration Sheet" is "just signed" by the patient on subsequent visits, but left blank except for the insurance information for billing purposes.

During an interview on 2/26/19 at 10:57 am, the CNM for the ED stated there in no alert within the EHR system to indicate if a patient has a legal guardian. He/she stated nurses rely on registration personnel to alert staff if a patient has a legal guardian.

The CNM of the ED further stated there is no written facility policy and/or procedure for