HospitalInspections.org

.
Based on record review and interview, the facility failed to provide a safe setting for one vulnerable Patient (#1) who presented to the Emergency Department (ED), escorted by LifeMed Alaska (a medical transportation service) and under a Notice of Emergency Detention and Application for Examination, called a Title 47 (An Alaska Statue [AS], 47.30.705, which authorizes the detention for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures). This failed practice resulted in Patient #1 receiving inadequate triage and observation during intake, which resulted in the patient leaving the facility before being evaluated, placing the patient at risk of potential harm to himself and to the community. Findings:

Record review on 11/8/23 revealed Patient #1's ED encounter timeline include he/she "Arrived" in the ED at 11:52 AM on 10/18/23 via LifeMed and was "Dismissed" at 12:54 PM. No assessments, interventions, or other interactions were noted in this timeline.

Further review of the record revealed: "Complaint ... combative and confused. Psych eval?... Clinical Impressions ... None... Disposition ... LWBS [Left Without Being Seen] before Triage ... "

Further review of the record revealed a total of 2 nursing notes:

1. "Pt [Patient] LWBS. ED Management and Security informed." This was electronically signed by Registered Nurse (RN) #1 on 10/18/23 at 12:54 PM; and

2. "Called APD [Anchorage Police Department] to report patient has left the facility without being seen, asking APD for a safety well check." This was electronically signed by RN #2 on 10/18/23 at 2:13 PM.

No other documentation was present in Patient #1's medical record, to include the ED triage.

Review of the hospital's investigation of this incident, which was initiated by RN #2 and dated 10/19/23 at 7:52 AM, revealed: "Patient was reportedly brought to PAMC ED via Lifemed from VA clinic. VA MD [Medical Doctor] did not call to alert of impending arrival. RN called stating patient needed mental health eval [evaluation], when ED Charge RN asked if the patient was a title 47/NED [need of emergency detention], the RN replied no. Lifemed also reported to charge RN if patient was on NED. Patient was taken to triage. Patient was registered by ED RN, then left the building directly ... Within the paperwork delivered by Lifemed, the patient did have a title 47 placed by a MD at the VA clinic [citing] the patient was unable to care for [himself/herself] safely and [he/she] was a risk to the community ..."

Review of an email, written by the Hospital Director of Physical Security and dated 10/20/23 at 12:41 PM, revealed a summary of the security video reviewed of Patent #1's ED encounter on 10/18/23:

- At 11:49 AM, the patient arrived with the LifeMed team. LifeMed handed the triage nurse a piece of paper, the patient had a wrist band placed on his/her wrist.

- At 11:55 AM, the LifeMed team helped the patient off the gurney and eventually into a bathroom, then LifeMed handed the triage nurse "numerous papers." LifeMed departed at 11:59 AM and Patient #1 returned from the bathroom and went to a chair in the ED area.

- At 12:04 PM, Patient #1 moved to a chair next to security, then departed the ED lobby at 12:06 PM.

Further review of Patient #1's medical record revealed no documentation of receipt or the contents of the LifeMed paperwork received from LifeMed Alaska. There was no documentation regarding any communication with the sending VA (Veteran Administration) provider or VA RN.

During an interview on 11/8/23 at 11:53 PM, the Program Manager of Regional Accreditation (PMRA) stated the ED triage nurse asked Patient #1 to wait while the RN called the VA and was told the VA provider, who place the patient under the Title 47, would call back. The PMRA further stated the RN who had completed Patient #1's ED intake was not aware of the Title 47. The patient had already left the facility by the time the provider called back.

During an interview on 11/8/23 at 1:34 PM, the ED manager stated he was unable to locate the LifeMed paperwork as it was not attached to medical record. The ED Manager further stated patients who come in under a Title 47 are typically triaged and assessed right away.

On 11/8/23, surveyors requested copies of the LifeMed paperwork that was delivered by Lifemed with Patient #1 on 10/18/23.

During an interview on 11/8/23 at 1:43 PM, the PMRA was not able to locate the Title 47 paperwork or the LifeMed paperwork and stated she called LifeMed to request a copy to be sent over as soon as possible.

Review of the LifeMed Alaska paperwork, which Providence received on 11/8/23 after requested, revealed a Title 47, dated 10/18/23, was in the packet. Further review revealed the Title 47 was initiated due to: " ... Probable Cause: Gravely disabled ... Veteran is severely cognitively impaired and unable to take care of [himself/herself] or keep [himself/herself] safe. [He/She] has been agitated and combative in the community ..."

Further review of the LifeMed Alaska paperwork revealed a "LifeMed Alaska Physician Certification Statement," dated 10/18/23, which was signed by a VA Social Worker and documented: "Describe services needed at receiving facility not available at referring facility: Pych [psychiatric] Eval [evaluation] / Inpt [inpatient] title 47 ... Describe the medical condition of the patient at the time of ambulance transport that required the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient's condition: gravely disabled ... Safety: Patient is confused, patient is combative at times, danger to self ..."

Further review of the paperwork revealed a "LifeMed Alaska Assignment of Benefits Signature Form and Receipt of Notice of Privacy Practices" form, dated 11/18/23, and a section at the bottom of the form titled "Receiving Facility Representative Signature." Further review revealed: "The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient ..." ED RN #3 signed this form on 10/18/23.

During an interview on 11/8/23 at 1:43 PM, the PMRA stated the facility investigation was determined to be a patient safety issue in the ED waiting room. When asked if any corrective measures were put into place after the investigation, the PMRA stated there was no plan of correction in place at this time.
.

.
Based on record review and interview, the facility failed to maintain an accurate written medical record for one Patient (#1) who presented to the Emergency Department (ED), escorted by LifeMed Alaska (a medical transportation service) and under a Notice of Emergency Detention and Application for Examination, called a Title 47 (An Alaska Statue [AS], 47.30.705, which authorizes the detention for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures). This failed practice placed the patient at risk for receiving incorrect interventions and an incomplete and/or incorrect medical record. Findings:

Record review on 11/8/23 revealed Patient #1's ED encounter timeline include he/she "Arrived" in the ED at 11:52 AM on 10/18/23 via LifeMed and was "Dismissed" at 12:54 PM. No assessments, interventions, or other interactions were noted in this timeline.

Further review of the record revealed: "Complaint ... combative and confused. Psych eval?... Clinical Impressions ... None... Disposition ... LWBS [Left Without Being Seen] before Triage ... "

Further review of the record revealed a total of 2 nursing notes:

1. "Pt [Patient] LWBS. ED Management and Security informed." This was electronically signed by Registered Nurse (RN) #1 on 10/8/23 at 12:54 PM; and

2. "Called APD [Anchorage Police Department] to report patient has left the facility without being seen, asking APD for a safety well check." This was electronically signed by RN #2 on 10/18/23 at 2:13 PM.

No other documentation was present in Patient #1's medical record, to include the ED triage.

Review of the hospital's investigation of this incident, which was initiated by RN #2 and dated 10/19/23 at 7:52 AM, revealed: "Patient was reportedly brought to PAMC ED via Lifemed from VA clinic. VA MD [Medical Doctor] did not call to alert of impending arrival. RN called stating patient needed mental health eval [evaluation], when ED Charge RN asked if the patient was a title 47/NED [need of emergency detention], the RN replied no. Lifemed also reported to charge RN if patient was on NED. Patient was taken to triage. Patient was registered by ED RN, then left the building directly ... Within the paperwork delivered by Lifemed, the patient did have a title 47 placed by a MD at the VA clinic [citing] the patient was unable to care for [himself/herself] safely and [he/she] was a risk to the community ..."

Review of an email, written by the Hospital Director of Physical Security and dated 10/20/23 at 12:41 PM, revealed a summary of the security video reviewed of Patent #1's ED encounter on 10/18/23:

- At 11:49 AM, the patient arrived with the LifeMed team. LifeMed handed the triage nurse a piece of paper, the patient had a wrist band placed on his/her wrist.

- At 11:55 AM, the LifeMed team helped the patient off the gurney and eventually into a bathroom, then LifeMed handed the triage nurse "numerous papers." LifeMed departed at 11:59 AM and Patient #1 returned from the bathroom and went to a chair in the ED area.

- At 12:04 PM, Patient #1 moved to a chair next to security, then departed the ED lobby at 12:06 PM.

Further review of the Patient #1's medical record revealed no documentation of receipt or the contents of the LifeMed paperwork received from LifeMed Alaska. There was no documentation regarding any communication with the sending VA (Veteran Administration) provider or VA RN.

During an interview on 11/8/23 at 11:53 PM, the Program Manager of Regional Accreditation (PMRA) stated the ED triage nurse asked Patient #1 to wait while the RN called the VA and was told the VA provider, who place the patient under the Title 47, would call back. The patient had already left the facility by the time the provider called back. When asked if those conversations should have been documented in the patient's chart, the PMRA agreed that it should have.

During an interview on 11/8/23 at 1:34 PM, the ED manager stated he was unable to locate the LifeMed paperwork as it was not attached to medical record. The ED Manager further stated patients who come in under a Title 47 are typically triaged and assessed right away.

On 11/8/23, surveyors requested copies of the LifeMed paperwork that was delivered by LifeMed with Patient #1 on 10/18/23.

During an interview on 11/8/23 at 1:43 PM, the PMRA was not able to locate the Title 47 paperwork or the LifeMed paperwork and stated she called LifeMed to request a copy to be sent over as soon as possible. When asked if this paperwork should have been apart of Patient #1's medical record, the PMRA stated that it should have been scanned in and attached to the medical record.

Review of the LifeMed Alaska paperwork, which Providence received on 11/8/23 after requested, revealed a Title 47, dated 10/18/23, was in the packet. Further review revealed the Title 47 was initiated due to: " ... Probable Cause: Gravely disabled ... Veteran is severely cognitively impaired and unable to take care of [himself/herself] or keep [himself/herself] safe. [He/She] has been agitated and combative in the community ..."

Further review of the LifeMed Alaska paperwork revealed a "LifeMed Alaska Physician Certification Statement," dated 10/18/23, which was signed by a VA Social Worker and documented: "Describe services needed at receiving facility not available at referring facility: Pych [psychiatric] Eval [evaluation] / Inpt [inpatient] title 47 ... Describe the medical condition of the patient at the time of ambulance transport that required the patient to be transported in an ambulance and why transport by other means is contraindicated by the patient's condition: gravely disabled ... Safety: Patient is confused, patient is combative at times, danger to self ..."

Further review of the paperwork revealed a "LifeMed Alaska Assignment of Benefits Signature Form and Receipt of Notice of Privacy Practices" form, dated 11/18/23, and a section at the bottom of the form titled "Receiving Facility Representative Signature." Further review revealed: "The patient named on this form was received by this facility on the date and at the time indicated and this facility furnished care, services or assistance to the patient ..." ED RN #3 signed this form on 10/18/23.
.