HospitalInspections.org

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Based on record review and interview, the facility failed to provide an appropriate Medical Screening Examination (MSE) for one individual (Patient #8) who presented to the Emergency Department (ED), with a police escort and under a Notice of Emergency Detention and Application for Examination, called a Title 47 (An Alaska Statue [AS], 47.30.705, which authorize the detention for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures), for assessment. This failed practice denied the individual an MSE, which violated the Emergency Medical Treatment and Labor Act (EMTALA), after it was requested on his/her behalf, in order to determine if stabilizing treatment was needed, or an appropriate transfer was required. Findings:

Record review on 10/2-3/23 and 10/5/23 revealed Patient #8, who was a minor, was escorted to the Alaska Regional Hospital's ED on 9/16/23 at 5:56 PM via police officer under a "Title 47" due to being a danger to others. The police officer escorted Patient #8 into the ED, presented the patient and the "Title 47" paperwork to the triage counter, and requested an assessment.

Further review revealed the ED's Charge Nurse #1 documented he/she went to the triage counter and received the "Title 47" paperwork from the officer: "APD [Anchorage Police Department] present with title 47, walked out to talk ... with officer. Made phone call to APD dispatch and officer confirmed that the local Pysch [psychiatric] facility [which at this time was Providence Hospital] was open. APD officers says 'sorry about that I dispatched the officer to the wrong place I will re dispatch them to the correct facility now ... Returned the paperwork back to APD officer after talking with DR [doctor] and dispatch. APD Officer states that she was re dispatched to psychiatric facility."

During an interview on 10/2/23 at 12:10 PM, the Chief Nursing Officer (CNO) and the ED Director both stated that on 9/16/23, the ED was on a "divert" status for psychiatric patients and had been for "months." The CNO and ED Director further stated the hospital had been on divert for months due to: 1) no resources of a licensed clinical social worker and they haven't had a psychiatrist on staff for 4 years; and 2) the rooms for psychiatric patients were "always full" and they did not have enough sitters (trained staff to sit with patients who require one on one observation for safety).

When asked how the hospital provided emergency services for patients who presented to the ED with psychiatric concerns, the CNO and ED Director stated the ED physicians would perform an MSE to rule out a medical emergency, then a tele-psych assessment would be requested virtually to rule out a psychiatric emergency, however the response time for this tele-psych requests could be up to 4 hours.

When asked about the hospital's investigation about the incident on 9/16/23, the CNO and ED Director stated they conducted a video review, which showed the police officer and Patient #8 stepped up to the triage window, in the ED, and after talking with staff left 11 minutes later without an MSE.

During an interview on 10/5/23 at 9:25 AM, Physician #1, who was on duty in the ED on 9/16/23, stated he/she did recall Charge Nurse #1 went to him/her to tell him/her there was a police officer with a "Title 47" patient, however he/she thought they were not yet on hospital property.

During an interview on 10/5/23 at 9:43 AM, Charge Nurse #1 stated that on 9/16/23 the facility was closed to psych because the ED was full. Charge Nurse #1 stated he/she was alerted from triage that a "Title 47" was out front. He/she went to talk with the officer, received the Title 47 paperwork, and returned to the ED to call APD Dispatch. Charge Nurse #1 stated APD Dispatch told him/her it was a mistake that the officer was dispatched to the facility's ED, and they will re dispatch them to the open facility, Providence Hospital, for assessment. Charge Nurse #1 stated he/she did talk with Physician #1 who was working in the ED on 9/16/23, with the "Title 47" in hand, and explained to Physician #1 a "Title 47" was out front and that APD Dispatch stated it was a mistake they were sent here, and the officer would be re dispatched to Providence Hospital ED. Physician #1 acknowledged this. Charge Nurse #1 further stated that when he/she went back out to the officer, the officer stated he/she had been re dispatched to the Providence Hospital ED and Charge Nurse #1 returned the "Title 47" paperwork. The officer and Patient #8 left after this.

Charge Nurse #1 stated he/she was familiar with EMTALA and the requirement for an MSE. In this situation he/she thought coming to the facility's ED was an error and at the time didn't think about the MSE requirement.

Review of Patient #8's "Notice of Emergency Detention and Application for Examination" (Title 47) form revealed: "Probable Cause: I certify that probable cause exists under AS 47.30.705 to believe that the above-named person is mentally ill and as a result of that condition is likely to cause serious harm to others of such an immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700."

Record Review from Providence Hospital ED, where the officer took Patient #8 after leaving Alaska Regional Hospital's ED, dated 9/16/23, revealed Patient #8 received an MSE and a psych evaluation.

Review of Patient #8's psychiatric evaluation, dated 9/16/23, revealed: " ...Due to the patient's increase in aggressive behavior which has escalated to the point of physical violence toward [his/her] stepmother, requiring her to seek medical attention, coupled with ongoing impulse control and mood dysregulation issues, patient appears to be at elevated risk outside of the hospital environment at this time ... Patient will be placed into psychiatric observation in the meantime for continued monitoring for safety while referral is pending ..." Further review revealed Patient #1 remained in the hospital overnight and was discharged 9/17/23 to an inpatient facility.

Record review of the facility's ED log showed multiple instances where police had escorted individuals to the ED under a "Title 47" and received an MSE and psychiatric screening before and after 9/16/23:

- Date: 9/4/23 - Patient #23 - Title 47: Likely to cause serious harm to self
- Date: 9/5/23 - Patient #11 - Title 47: Gravely disabled
- Date: 9/9/23 - Patient #24 - Title 47: Likely to cause serious harm to self
- Date: 9/13/23 - Patient #25 - Title 47: Likely to cause serious harm to self
- Date: 9/17/23 - Patient #26 - Title 47: Gravely disabled
- Date: 9/21/23 - Patient #27 - Title 47: Likely to cause serious harm to self
- Date: 9/24/23 - Patient #28 - Title 47: Likely to cause serious harm to self
- Date: 9/25/23 - Patient #29 - Title 47: Gravely disabled, Likely to cause serious harm to self and others
- Date: 9/27/23 - Patient #30 - Title 47: Likely to cause serious harm to self
- Date: 9/28/23 - Patient #31 - Title 47: Likely to cause serious harm to self and others

Review of the facility's policy "Hospital EMTALA Medical Screening Examination and Stabilization," dated 9/2023, revealed: " ... An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and: 1. The individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition ... A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC [emergency medical condition] exists ... [to] an individual who has such a request made on his or her behalf ..."

Further review revealed: " ...Note: A hospital my deny access to individuals when it is in "official diversionary" status because it does not have the capability or capacity to accept any additional emergency individuals at the time. The hospital shall develop and adopt written criteria that describe the conditions under which any or all of the hospital's emergency services are deemed to be at maximum capacity. Caution: If the ambulance staff disregards the hospital's instructions and brings the individual on to hospital property, the individual has come to the emergency department and the hospital must perform an appropriate MSE ..."

Review of Alaska Statute (AS) 47.30.705(a) revealed: "A peace officer ... who has probable cause to believe that a person is gravely disabled or is suffering from mental illness and is likely to cause serious harm to self or others of such immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures set out in AS 47.30.700, may cause the person to be taken into custody by a peace officer ... and delivered to the nearest ... evaluation facility or treatment facility ..."
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