HospitalInspections.org

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Based on observation and interview the facility failed to ensure signage informing patients of the Emergency Medical Treatment and Labor Act (EMTALA) was posted conspicuously in the Emergency Department (ED) in places to be noticed by patients entering the ED, or places likely to be noticed by patients waiting for examination and treatment in areas. These failed practices denied patients access to information about their right to examination and treatment of emergency medical conditions and women in labor. Findings:

Random observations from 2/25-28/19 of the ED revealed no EMTALA signage when entering the ED from the ambulance bay or in areas where patients would be examined or treated.

During an interview while on a walkthrough of the ED, on 2/28/19 at 2 pm, the Clinical Manager of the Emergency Department stated there was no EMTALA signage in the ambulance bay entrance and in the exam and treatment areas of the ED.

Review of the hospital policy "EMS/EMTALA Administrative Procedure #713-04B Reference Policy: EMS/EMTALA Policy #713" revised date of May 2017, revealed "...4.4 Notification of Rights: ANMC will post signs notifying individuals of their eligibility to receive a Medical Screening Examination and, if needed, stabilizing treatment and/or an appropriate transfer ...The signs will be posted conspicuously in places likely to be noticed by all individuals entering or waiting for care in the emergency department ...and other appropriate locations ..."

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Based on record review, interviews, video reviews, and policy reviews, the facility failed to ensure that 2 prospective patients (#s 4, and 31), out of 30 patients emergency room (ER) visits reviewed, had received a medical screening exam as requested. In addition, the facility's policy of trespassing individuals from the property, even after they had requested a MSE for a medical emergency denied them of their right to a medical exam and stabilizing treatment and placed individuals presenting to the facility at risk for further harm and/or death from untreated medical conditions. Findings:

Review of a potential EMTALA (emergency medical treatment and labor act) violation, self-reported by the facility on February 25, 2019, revealed Patient #4 had checked into emergency department (ED) and was waiting for a medical exam in the waiting room when Security Officers (SO), recognized Patient was on the "trespass" list and removed him/her from the premises before the Patient had received a medical screening exam.

INTERVIEWS: TRESPASSING

During an interview on 2/27/19 at 11:10 am, Security Officer (SO) #6 stated Patient #4 had been trespassed for more than 7 years. SO #6 further stated when they (the security officers) trespassed them (patients) so often the SO didn't have time to give the patient the paper (trespass paper the SO fills out informing the patient of the trespass and the length of the trespass).

During an interview on 2/28/19 at 10:05 am, the facility Chief of Security revealed the following when asked to describe the "trespass" process/program revealed the following:

1. The facility did not have a policy in place governing the trespass program.
2. The facility had no curriculum in place for security personnel aimed at trespass procedures.
3. The trespass program prohibits those placed on the trespass list from being on campus for other than medical reasons.
4. There were many periods a person could be trespassed; 30, 60, 90 days, one year and indefinitely.
5. There was no definition or instruction explaining the determination to the length a security officer could trespass a person.
6. If an individual was on the trespass list they were instructed to check in with security 15 minutes prior to medical appointments unless was an emergency.

Prior to escorting a trespassed individual off campus, security was required to ask if they had checked in with medical personnel. If treatment were required, security would remove the individual. The Patient was expected to leave once services had been provided.

During Interviews conducted on 3/1/19 at 1: 25 pm, three different security officers (SO#1, SO#2, and SO#3) were asked how timeframes for trespasses were determined, SO #1 reported a senior officer determines the timeframes, SO #2 reported, it depended on the severity of reactions from the person, and SO #3 reported it was a case by case basis.

During an Interview on 3/4/19 at 9:25 am, the Vice President of Administrative Services (VPAS) (who oversaw security) stated the facility had no guidelines for defining or administering 30, 60, 90, one year, or indefinite trespasses for all patients.

INTERVIEWS: MEDICAL SCREENING EXAM

During an interview on 2/28/19 at 10:40 am, the Chief Ethics & Compliance Officer (CECO) stated Patient #4 had not received an MSE, after presenting to the ED for treatment.

During an interview on 2/28/19 at 2:00 pm, the Clinical Manager of the Emergency Department (CMED) stated Patient #4, had checked with LN #1, the triage nurse, requesting to seen for a medical emergency, but the Patient had not received a MSE.

During an interview on 3/1/19 at 8:00 am, LN #2 stated Patient #4 was seen by the Nurse 1st (a nurse in the ED who checked in patient to the ED to be seen) nurse who also triaged Patient #4. LN #2 further stated, "(Patient #4) was not seen by the ED doctor." Security officers escorted Patient #4 out of the ED before he/she was seen.

During an interview on 3/4/19 at 9:50 am, the VPAS stated, the "standards everyone [who presents to the ED] has to be seen."

VIDEO REVIEW

A video review was conducted on 2/27/19 at 11:40 am, with the Director of Safety (DS). Review of the video revealed on 2/24/19 at 7:42 pm, Patient #4 walked into the facility ED entrance, stood next to the HIPAA sign waiting, walked waiting area and sat down. The Patient then stood up entered into the "Nurse 1st" area at 7:45 pm, (an area in the ED where patients come to check in with a nurse to be seen in the ED). At 7:52 pm, Patient #4 walked out of the Nurse 1st room, walked down the hall, past the security stand (no security guard present) toward an alcove area on Patient #4's right side where vending machines were located. The Patient stood there until 7:54 pm, when he/she walked back to the security stand area. An unidentified female approached the Patient. They both walked back to the vending machines. At 7:55 pm, Patient #4 left the vending area and was met by two SOs who stopped Patient #4 at the corner of the vending area. The SOs walked Patient #4 back to the ED waiting area where Patient #4 sat alone in a waiting room chair. Next, as the Patient sat in the waiting room, the two SOs reproached the Patient, and had him/her stand up. At 7:56 pm, two SOs walked Patient #4 to the outside of the facility and stood and watched as Patient #4 walked off the facility property.

RECORD REVIEW

Record review on 2/28/19 at 9:00 am, of the Nurse 1st log, for 2/24/19 revealed Patient #4 was seen by Licensed Nurse (LN) #1 arrived at 19:46 (7:46 pm) and triaged (an assigning of degree of urgency to decide the order of treatment for patients) at 19:48 (7:48 pm). Disposition listed as "LWBS [left without being seen] AFTER Triage."

Record review on 2/27/19 at 2:00 pm, of a Behavioral Health Note, dated 2/24/19 20:44 (8:44 pm), from Licensed Clinical Social Worker (LCSW) revealed "Telephone call from Psych ED at Providence requesting records. Pt was brought there, reporting hallucinations and suicidal thoughts. Reported ANMC will not help him ..."

Record review on 2/28/19 at 7:59 am, revealed "ED/Triage Note/Assessments" dated 2/24/19 19:48 (7:48 pm,) by LN #1, "Triage Chief Complaint: Pt c/o [-complained of] left arm pain ...states (Patient #4) resents to ED secondary to left arm pain ..."

Record review on 2/28/19 at 4:00 pm, of Providence Alaska Medical Center (PAMC) "ED Triage Notes" dated 2/24/19 at 21:40 [9:40 pm], revealed " ...PT BIB [brought in by]self voluntary ...Pt noted 'I've been hearing voices and seeing things. ANMC security kicked me off the property and then I walked here' ...Patient arrived with a BRAC [breath alcohol content] of 0.0 ..."

2nd PATIENT

Record review on 2/28/19 5:00 pm, of a facility investigation, dated 12/22/18 at 10:07 pm, revealed On Saturday December 7th, 2018 at 2207 (10:07 pm) un-sampled Patient #31 was walking toward the outside ED entrance where SO #4 was sitting down. Patient #31 asked SO #4 for money, SO #4 asked the patient if the patient was trying to check into the ED, the patient replied yes, also yelling in slurred speech. SO #5 then approached the patient and stated if he/she did not stop (behaviors) he/she could leave. The two SO's eventually escorted the patient off campus without medical care.

Review of the ED log for 12/22/18 reveal Patient #34 had never checked into the ED or received a MSE.

3rd PATIENT

Record review on 2/28/19 of a facility investigation, dated 9/21/18 at 10:32 pm, revealed On September 21, 2018 at 2232 (10:32 pm) hours a security officer (name of SO) trespassed "[name of patient] for 90 days. [Name of patient] was loitering in the ED lobby ..." Further review of the document revealed no documentation of the SO asking if the Patient wanted to be seen in the ED as he was in the ED lobby.

Review of multiple facility investigations from 2/28/19 to 3/4/19 revealed the following:

-Dated 9/12/18 at 5:32 pm, SO's approached a prospective patient in a parking lot on ANMC property. The SO's called after him/her, then he/she started running toward Tudor road (a main highly traveled road near the facility). When the SO's caught up to him/her, he/she was at Tudor road with many cars passing. The SO grabbed him/her to avoid him/her getting hit by a car.

-Dated 9/13/18 at 11:28 pm, the SO "escorted [patient name] out of the ANMC property [patient name] ran out on the road an in front of an on-coming life-med truck ...[SOs] had to physically force him to get off the road. [SO name] trespassed [patient name] for 1 year."

-Dated 9/21/18 at 11:32 pm, the SO trespassed [patient name] for 90 days for loitering in the ED.

-Dated 12/5/18 at 5:30 pm, SO's found a person sleeping in a lounge. They woke up the person (who they found highly intoxicated) and escorted the person outside to the bus stop and helped the person sit on the bus stop bench. The person was trespassed for 1 year.

Review of the facility's policy titled "Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) General Procedure # 713-02B", last revised 5/17, revealed:

"Purpose: to ensure all individuals at the Alaska Native Medical Center (ANMC) accredited campus have access to essential emergency medical care in accordance with the Emergency Medical treatment and Labor Act (EMTALA), 42 USC Section 1395dd ..."
"4.3. Applicability: This procedure applies to all individuals, even if they are not eligible for or cannot pay for other direct health care services, who:"
"4.3.1. come to the Emergency Department and request or appear to need examination of treatment for a medical condition of any kind;"
"4.3.7. are on the accredited campus or within 250 yards of the hospital or Primary Care Center buildings seeking or in apparent need of medical care."


Review of the facility's policy titled "Emergency Medical Services and the Emergency Medical Treatment and Labor Act (EMS/EMTALA) Policy #713B", last revised 5/17, revealed:

" ...3.1. In accordance with EMTALA, ANMC [Alaska Native Medical Center] will ensure an appropriate Medical Screening Examination by a physician or qualified medical personnel is available for all individuals requesting emergency medical care ..."
" ...3.3. Medical Screening Examination will be performed by a physician or qualified medical personnel within the capability of the Emergency Department, including ancillary services routinely available to the Emergency Department during the time the individual is examined."
" ...3.9. ANMC will adopt and enforce such procedures and practices as may be necessary to ensure compliance with EMTALA."


Review of the facility's policy titled "Campus Security Program Procedure # 802E", last revised 12/18, revealed:

"3.3.4. Security Officers shall use the least amount of force necessary to restrain or to control situations such as a combative or unruly individual or to escort an individual as directed by a responsible health care provider."
3.3.4.1. "ANMC staff are encouraged to call for Security assistance when they are being threatened or observe threatening behavior."
3.3.4.2. "Security Officers should take care to have sufficient assistance on hand to minimize the danger to all concerned."
"3.3.9. "Documentation of security incidents/activities: Security Officers will document their activities using activity logs and incident reports."
3.3.9.2. "Patients or visitors who do not follow ANMC's behavior expectations as detailed in the Patient Rights and Responsibilities may be trespassed from the campus for a time period determined by the offense."

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