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Based on review of the hospital's Medical Staff Bylaws, medical staff and emergency department policies and procedures, clinical record review and staff interviews, the hospital failed to ensure the Medical Staff Bylaws, and Rules and Regulations of the Medical Staff clarified who can perform medical screening exams. In addition, the hospital failed to ensure an appropriate mode of transportation was utilized for transfer of an acutely ill patient to another hospital. These failed practices placed patients at risk for potential complications.

Review on 7/2/12 of the Medical Staff Bylaws revealed the bylaws did not define the personnel qualified to perform emergency medical screening examinations.

Based on record review and interview, the hospital failed to maintain a complete central log for all individuals who came to the hospital seeking examination or treatment for a potential emergency medical condition. Findings:

Review of the Emergency Department (ED) Log on 7/2/12 revealed a hand written log book which included columns for date; name; age; physician's name; nature of illness/injury; nurse's name; patient's disposition; and disposition time. Further review of the ED log for January - June 2012 revealed multiple occurrences where columns were left blank or patient information was lined out. For instance, during the month of June 2012 there were 24 instances where the patient disposition was left blank; 12 instances where the nature of illness/injury was left blank; 8 instances where patient information was lined though/marked out and 6 instances where the physician name was left blank.

During an interview on 7/3/12 at 8:15 am, when asked about the missing documentation, Registered Nurse (RN) #1 confirmed the ED log was incomplete and the expectation was that nurses complete the ED log and fill in each column with the appropriate information.

During a tour of the ED on 7/2/12 at 9:30 am, RN #2 stated the only patients entered into the ED log are the patients who are seen in the ED. In addition, RN #2 stated a separate log is maintained for the patients who are seen through the "Fast-Track" area.

Review of the "Fast-Track" log on 7/2/12 revealed a hand written log titled "Welcome To NSHC Outpatient Clinic." Review of this log for the dates 6/20/12-6/29/12 revealed a one page document for each day which included Patient Name, City, Arrival time, Age, and Physician Name. There was not an area on this log for staff to document the nature of illness/injury nor the disposition.

During a second interview on 7/2/12 at 2:00 pm, RN #1confirmed the "Fast Track" log did not contain necessary information such as the nature of illness/injury nor the disposition.

Based on record review and interview, the hospital failed to ensure a patient was transferred to another hospital utilizing an appropriate mode of transportation. Findings:

Record review on 7/3/12 revealed Patient #1 came to the Emergency Department (ED) on 6/22/12 at 12:51 pm with complaints of right lower quadrant abdominal pain, right flank pain, and bladder pain. The nurse completed a triage exam and determined the patient could be seen in the Fast Track area. Patient #1 received a medical screening exam and treatment from Physician #1 in the Fast Track area. Tests were ordered and completed, including a CT Scan of the abdomen and pelvis. Results were positive for acute appendicitis. Due to the hospital's inability to perform surgery, the physician made arrangements for the patient to be transferred to a hospital in Anchorage for surgery. There was documentation that a physician at the Anchorage hospital had agreed to accept the patient. The medical record was copied and sent with the patient, who was then transferred to the Anchorage hospital via commercial airline instead of by Medivac.

Further review on 7/3/12 of Patient #1's record revealed "Given risks including getting sicker and death if does not follow plan." However, there was no documented evidence that the hospital explained the risks of transfer via commercial airline to the patient.

During an interview on 7/2/12 at 2:15 pm, when asked about Patient #1's transfer, Physician #1 confirmed that in his medical opinion Patient #1 was stable at the time of transfer and could safely be transferred by commercial airline. In addition, Physician #1 stated he followed up with Patient #1 several days after the transfer and she seemed to be doing well after surgery.

Review of the hospital policy & procedure titled "Transfer of Patient W/An Emergency Medical Condition To Another Acute Care Facility", revised 9/7/00, revealed "...Procedure: ...3. The physician will: ...f. Have patient or family member sign hospital Consent to Transfer form. g. Sign the Physician Certificate to Transfer."

Further record review on 7/3/12 revealed no documented evidence of completion of either the Consent to Transfer form nor the Physician Certificate to Transfer form.