HospitalInspections.org

Based on interview and record review the facility failed ensure a medical screening exam (MSE) was completed for each patient who presented to the ED seeking care and services; 2) the medical staff bylaws, rules and regulations clarified the training required for an RN to perform a medical exam and ensure it had been completed; and 3) developed policies and adopt best practice standards for ED triage performed by the nurses. These failed practices potentially denied patients access to being informed about their rights to a MSE and failed to give nursing clear directions as to their role in triaging ED patients. Findings:

During multiple interviews with RN's, unit clerks, the Assistant Administrator, and the Medical Director from 8/19-21/15 revealed the physicians, nursing staff and unit clerks had been trained to follow the policy below during the month of July 2015. All staffs interviewed stated the policy for "Process for Admission to the Emergency Department" was in fact being done. In addition all staff interviewed stated that neither vital signs, nor a nursing assessment would be documented if the patient chose to be seen at the clinic and not in the ED. In addition, the RN stated the medical screening exam (MSE) was done only by the MD in the clinic or in the ED and never by the RN.

Record review of the EMTALA training that occurred between 7/16-31/15 revealed all health care staffs had received EMTALA training to include the following policy.

Record review of the policy "Process for Admission to the Emergency Department" last revised 9/07, revealed:

"Providence Valdez Medical Center will provide a medical screening exam to all patients presenting to Hospital Emergency Department ...;

Nursing Staff Responsibilities initiating ER services:
1. In the ER, the RN shall triage the patient.

2. The RN will call the on-call physician. When calling the clinic, the nurse will convey to the front desk the category or level in order for the physician to understand what level of response is required ....;

Patients Presenting with a Questionable Emergency Condition:

When a patient presents at the front desk of Admitting or Nurse's desk and is looking for direction, the nurse may provide them with the choice; the patient may:

¿ Remain in the ER to be seen by the MD in priority order.
¿ Go to Valdez Medical Clinic or alternate site for services...

Physician Responsibilities:

1. Perform the medical screening exam in person.
2. Provide evaluation and oversee all treatment for patients.
3. Provide information and consultation to the RN when requested.
4. Meet all the requirements of the ER contract."


Record review of the Professional Staff Rules and Regulations, latest revision 3/5/12, page 46 revealed,

"Medical Screening Examination: Medical screening examinations within the capability of the Hospital will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified medical personnel who can perform medical screening examinations are defined as: ...2.The trained RN for adults for Pediatrics will triage and initiate standing protocols as appropriate for every patient who presents to the Emergency Department.. "

Physician Contract

Record review on 8/21/15 of the "Professional Service Agreement between Valdez Medical Clinic, LLC and Providence Health & Services Alaska", dated 8/17/15, revealed "Exhibit A, Standards for Services:... d. Respond to Providence when requested to attend to patient in a timely manner and complete a medical screening examination or provide stabilizing care..."

Further review of the facility policies provided revealed the facility did not have a triage policy, nor had the facility adopted a best practices standard for Triage of ED patients. In addition, review of the nurse staffing education files did not reveal specific education for the triage process of adult and pediatric patients presenting to the ED requesting a medical screening exam.


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Based on record review and interview the facility failed to ensure all persons presenting on the hospital campus requesting care and services for health concerns were registered and recorded on a central Emergency Department (ED) log. Failure to keep a log of all patients presenting to the ED for care and services denied patients the right for the facility to track and review care and services provided to each individual patient presenting to the ED. Findings:

Record review from 8/19-21/15 revealed the facility was keeping 2 ED logs. The primary ED logbook listed patients in chronological order by date that had been admitted or registered to the ED. This log also included the medical record number, time, chief complaint, admitting nurse, physician, and disposition.

The second ER Log named the "Triage Log" had been implemented on or before 7/21/15 and revealed persons that either called or presented to the nurses station requesting health care services. This log did not always have a patient name or time of arrival. In addition, the Triage Log rarely had patient identification information. In comparing the two logs by the chief complaints listed on the Triage Log; those patients on the Triage Log, who had been send to the clinic for cares had not been registered to the ED and had not received a medical screening exam.

The Triage Log had 24 entries. The entries included 10 telephone advice calls and 14 persons who had presented on hospital campus for health concern evaluation.

During an interview on 9/20/15 at 9:45 am the Assistant Administrator stated the ED had implemented 2 logs for the ED. The ED Log was for those patients who were provided care and services in the ED and a second log for those patients who presented for care and services in the ED but were given the option of the ED vs the clinic.



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Based on record review and interview the facility failed to ensure all patients who presented to the Emergency Department (ED) for care and services were provided a medical screening exam (MSE) by a qualified provider and failed to identify what a medical screening exam included. These failed practices denied patients who presented to the ED their rights to a MSE by a qualified provider and placed them at risk for not receiving emergency care and services. Findings:

Based on record review and interview the facility failed to ensure all persons presenting on the hospital campus requesting care and services for health concerns were registered and recorded on a central ED log.

The second ED log named the " Triage Log " had been implemented on or before 7/21/15 and revealed persons that either called or presented to the nurses station requesting care and services in the ED. The patients listed on the Triage Log had not been registered to the ED, rarely had a name, did not receive a defined triage assessment, nor did they receive a medical screening exam.


"Triage Log" created on or after 7/21/15 revealed:

"7/21/15 at 8:30 am Escorted to clinic to be seen as a walk-in. Experiencing H/A [headache] for past 3 days and emotional;

7/23/15 at 1:35 pm female from OOT [out of town]; fish hook in (R) knee informed nurse who was with another patient. I [unit secretary] offered ER vs Clinic when walk in hours were. She said she preferred going to clinic and waiting 25 minutes till 2:00 pm. Escorted over to clinic by [staff]. Informed [RN] that patient went to clinic and she [RN] said that was appropriate [unit secretary initials];

7/23/15 [no time] Walk-ln: arrived with gramma via wheelchair. Has been in auto accident-R leg bandaged-states broke back and other hospital gave her crutches only. States will only see her Dr. and not the others. [curse quote] as she is under pain contract with [MD name]. Opted to be seen in clinic so could have more of a chance of choosing her physician as ER [patients] accepts which ever MD the clinic send, also the ER does not as a general rule, dispense pain medication;

7/23/15 at 7:55 am states needs to see a doctor, I am from out of town and it is not an emergency. Patient given the following options: 1) to be seen now in the ED, 2) to be seen in clinic walk-in hours 9-11 or 2-4. Pt. chose clinic option and escorted by staff. No medical screening had been completed after presenting to the hospital for medical care and services;

7/26/15 [no time] Walk-in: Fever for past 24 hours with nausea no emesis, taking APAP [tylenol] every 4 hours, concerned about cost, no insurance. No open wounds visibly infected no other symptoms. Pt informed clinic open tomorrow at 8:00 am, can alternate APAP and ibuprofen no more than 4000 mg APAP and 3800 mg Ibuprofen in a 24 hour period, cool compresses, light bedding. Take food with Ibuprofen. Can be seen in hospital or call if new symptoms if want to wait for clinic. Pt decided to go to clinic in am;

7/29/15 at 11:00 am tooth infection jaw swollen. Opted for clinic visit, is aware can return to ER if chooses;

8/4/15 [no time] finger lac to R hand yesterday on fishing vessel. Given option to be seen in the ER or clinic-requested clinic - escorted;

8/4/15 [no time] Walk in: H/A [head ache] and nausea unrelieved with APAP or Norco seen in clinic yesterday 9 weeks pregnant. Pt spoke with Dr. Todd via telephone;

8/5/15 [no time] Walk-in: See a Dr. about a cold, choice given to walk-in re ER MD or clinic, He chose to go to clinic tomorrow; informed if he gets worse or wants to can return to ER;

8/6/15 at 4:30 am Employee at Silver Bay arrived with complaints of numb feet. Eval to find pt. feet very cold. Warmed with blankets, given warm fluids. Symptoms resolved, pt. wearing 1 layer of socks, rubber boots, not insulated. Educated on hypothermia, frostbite, and workplace safety/prevention. MD not called. Pt did not need to be seen;

8/6/15 at 11:00 am twisted ankle at work, would like to try clinic 1st unsure where clinic was or its availability;

8/6/15 [no time] Walk-in: Male adult, fish hook left index finger? opted to be seen at clinic;

8/7/15 at 2:00 am Walk-in: Localized papules around recent abrasion-started after band-aid application. Has not tried po [oral] or topical. Arrives to ER and is traveling to Denali tomorrow and afraid to be on the road if things get worse. MD called, review of symptoms; band-aide application-papules around band-aide, pt denies chickenpox/shingles. Recommendation: per MD 1% hydrocortisone QID [4 times a day] Benadryl PO; Aveeno topical. F/u if worse, walk-in clinic in am after travel or ED if worse;

8/10/15 at 3:40 am Walk-in: Dad - for [patient name] Fever at home been treated with Motrin x 2 doses last dose 20 minutes before arrival. Fever 102 at home. Quick tympanic temp as walk-in was 101.3. Father concerned about fever. Response given: Continue with motrin as prescribed by wt. based dose on bottle if symptoms/fever worsen come back to ER or clinic. Balance of nursing assessment wholly unremarkable. Physician contracted [contacted]: N/A;

Review of the ED log from 7/21/15 - 8/19/15, looking a chief complaints, dates, and times, revealed none of the persons who were written on the Triage log had been registered in the ED log for the same complaint.


During an interview on 8/21/15 at 9:45 am Dr. Cullen, the Medical Director stated patients who presented to the nurses station requesting to see a physician were given the option of being seen in the ER or going to the clinic during the clinic walk-in hours. When asked if he or his physician group had delegated in writing that the RN could perform the medical screening exam, he stated they had not. In addition, was not sure if the medical staff bylaws or rules and regulations had defined a medical screening exam.

During an interview on 8/21/15 at 10:30 am the Director of Nurses stated the facility had not adopted a triage protocol based on best practice standards and did not have a policy that defined a triage assessment.