The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SITKA COMMUNITY HOSPITAL 209 MOLLER DRIVE SITKA, AK 99835 July 27, 2017
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on record review the facility failed to:

1) define in the medical staff by-laws the educational and competency requirements of nursing staff to perform medical screening exams and

2) define in the medical staff by-laws the process of peer review for each person deemed appropriate to perform a medical screening exam. Findings:

Record review of the "Medical Staff Bylaws, Rules and Regulations", revised 4/27/17, revealed "The term Medical Staff comprises those medical professionals who are ....Privileged to take part in treatment of patients...A history and physical examination in all cases shall be performed on admission ...to the ER ...OB Services ...obstetrical patients admitted for labor and deliver that have had prenatal care ....Shall nevertheless have a brief current review of history and physical examination and findings recorded."

The Bylaws further define "Emergency Department patient do not need a formal discharge summary but the physician note ...should clearly state the current treatment and follow up plan."

Further review of the Bylaws revealed no educational or competency requirements of nursing staff to perform MSE's and no peer review process for persons who perform MSE's.



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VIOLATION: POSTING OF SIGNS Tag No: C2402
Based on observation the facility failed to ensure signage informing patients of the Emergency Medical Treatment And Labor Act (EMTALA) was posted at all entrances to the Emergency Department (ED), the ED registration desk, ED treatment area and the obstetrics department. This failed practice denied patients immediate access to information about their right to a Medical Screening Exam. Findings:


Observations on 7/27/17 from 12:00 pm - 1:30 pm, revealed no EMTALA signage present at the ED entrance, ED registration desk, in the ED treatment area, or in the OB triage/treatment rooms.

The findings were confirmed during a tour on 7/28/17 at 11:00 am of those areas with the Acute Care/ED Manager.



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VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on record review, interview and policy review the facility failed to ensure patients (#s 1-12) who had presented to the Emergency Department (ED) and patients (#s 19-22) who had presented to the Obstetrics (OB) triage desk were provided with medical screening exams (MSE) by a qualified provider (physician or midlevel practitioner) to determine if a medical emergency existed prior to discharge. These failed practices denied all patients who presented to the ED and OB their rights to a MSE by a qualified provider and placed them at risk for not receiving emergency services. Findings:

Record reviews of the ED and OB logs on 7/26-27/17 revealed:


Patient #1

Review of the ED log entry, dated 1/19/17 at 2:31 pm, revealed Patient #1 presented to the ED with chief complaint of "foot injury."

Review of the ED record, dated 1/19/17, revealed no documentation of an MD MSE.

Disposition: 2:58 pm "pt left by ambulation to walk in clinic."


Patient #2

Review of the ED log entry, dated 1/13/17 at 2:43 pm, revealed Patient #2 presented to the ED with chief complaint of "lacerated hand."

Review of the ED record, dated 1/13/17, revealed no documentation of an MD MSE.

Disposition: 3:40 pm "Discharge to MSFHC after case reviewed with [Provider #1]."


Patient #3

Review of the ED log entry, dated 3/15/17 at 1:07 pm, revealed Patient #3 presented on with chief complaint of "R shoulder pain."

Review of the ED record dated 3/15/17 revealed no documentation of an MD MSE.

Disposition: 1:31 pm "I spoke with [Provider #2]. He will see her immediately. I put her back in her wheelchair and escorted her to the clinic. [Provider #2] aware of BP [232/92]."


Patient #4

Review of the ED log entry, dated 3/18/17 at 12:33 am, revealed Patient #4 presented to the ED with a chief complaint of "R foot laceration."

Review of the ED record, dated 3/18/17, revealed no documentation of an MD MSE.

Disposition: 12:45 am "May be discharged from ER per EMTALA Guidelines: yes; Physician notified on 3/18/17 at 12:59 pm", greater than 12 hours after the ED admission.

Further review of the record revealed "00:59 patent came to the ER because he kicked his foot with an exacto blade and it was really bleeding. "I was scared it was my artery." Bleeding had stopped upon arrival and no laceration worthy of stiches noted. Patient stated his tetanus shot was done last year. Patient given a bandaid and reassured and left to home. No care required. Dr. notified."


Patient #5

Review of the ED log entry, dated 3/23/17 at 4:38 pm, revealed Patient #5 presented to the ED with a chief complaint of "asthma."
Review of the ED record, dated 3/23/17, revealed no documentation of an MD MSE.

Disposition: 4:49 pm "Patient here from silver bay for a new inhaler. Spoke with [Provider #2] who seen the patient and gave the patient a prescription for his inhaler and advised to come to the clinic tomorrow. Patient very agreeable. Denies SOB. Lung sounds clear and unlabored. Denies discomfort. Arm band removed and patient left to go to the Pharmacy to fill his prescription for albuterol puffer."



Patient #6

Review of the ED log entry, dated 3/25/17 at 5:25 pm, revealed Patient #6 presented to the ED with a chief complaint of "L thumb injury."

Review of the ED record, dated 3/25/17, revealed no documentation of an MD MSE. The record also revealed a tetanus injection was given per a telephone order.

Disposition: 6:35 pm "left thumb cleansed very well and irrigated after soaking finger for 10 min ...applied dermabond per MD order [no order documented for dermabond] ...discharged to home stable ..."


Patient #7

Review of the ED log entry, dated 7/15/17 at 8:09 pm, revealed Patient #7 presented to the ED with a chief complaint of "fell on bike."

Review of the ED record, dated 7/15/17, revealed no documentation of an MD MSE.

Disposition: 9:00 pm "discharged to home or self care, EMTALA." Clinic was not open at this hour.


Patient #8

Review of the ED log entry, dated 4/27/17 at 6:44 am, revealed Patient #8 presented to the ED with a chief complaint of "flu."

Review of the ED record dated 4/27/17 revealed no documentation of an MD MSE.

Disposition: 7:25 am "EMTALA to clinic per Dr. Smith."


Patient #9

Review of the ED log entry, dated 7/6/17 at 2:22 pm, revealed Patient #9 presented to the ED with a chief complaint of "fell and injured R arm."

Review of the ED record, dated 7/6/17, revealed no documentation of an MD MSE.

Disposition: 2:35 pm "Patient was briefly evaluated by [Provider #3] and advised of option to have laceration treated at Mountainside Family Healthcare. May be discharged from ER per EMTALA guidelines."


Patient #10

Review of the ED log entry, dated 5/19/17 at 6:35 am, revealed Patient #10 presented to the ED with a chief complaint of "numbness and tingling both arms."

Review of the ED record, dated 5/19/17, revealed no documentation of an MD MSE.

Disposition: 6:55 am "EMTALA."


Patient #11

Review of the ED log entry, dated 6/28/17 at 8:14 am, revealed Patient #11 presented to the ED with a chief complaint of "R hand injury."

Review of the ED record, dated 6/28/17, revealed no documentation of an MD MSE.

Disposition: 8:42 am "To clinic."


Patient #12

Review of the ED log entry, dated 6/19/17 at 11:54 am, revealed Patient #12 presented to the ED with a chief complaint of "abd pain."

Review of the ED record, dated 6/19/17, revealed no documentation of an MD MSE.

Disposition: 12:36 pm "May be discharged from ER per EMTALA guidelines."



Denied Care in the ED

ED Patient #13

Review of the ED log entry, dated 3/25/17 at 12:13 pm, revealed Patient #13 presented to the ED with a chief complaint of "R abd pain."

Review of the ED record, dated 3/25/17, revealed "Patient stated she did not want to go to clinic and only see a NP. She then ambulated out of the building stating she would file a grievance that the Dr. wanted to EMTALA her to clinic."

Disposition: 12:45 pm, no documentation MD was notified.


ED Patient #14

Review of the ED log entry, dated 5/13/17 at 2:15 pm, revealed Patient #14 presented to the ED with a chief complaint of "Chest pain."

Review of the "AMA-Release of Responsibility for Discharge" form signed by the Patient on 5/13/17 at 3:30 pm revealed no documented risks involved with leaving against the advice of a physician. In addition, the medical record did not have documentation of the risks of leaving AMA.

Disposition: 3:30 pm.


ED Patient #15

Review of the ED log entry, dated 4/3/17 at 4:42 pm, revealed Patient #15 presented to the ED with a chief complaint of "back pain."

Review of the ED record, dated 4/3/17, revealed the patient was given IM medications. Further review of the ED record revealed no MSE documented by the MD.


OB Patients

OB Patient #19

Review of the OB log entry, dated 2/28/17 at 9:15 pm, revealed Patient #19, with an estimated due date of 3/13/17 presented to the ED registration desk for possible onset of labor and cramping.

Further review, revealed the nurse contacted the MD and telephone orders were received for "NST, SVE, observe x 1 hour if no change may dc home. F/U clinic as prev. scheduled."

In addition, the following was revealed "Diagnosis: False Labor-undelivered." No documented MSE by MD.


OB Patient #20

Review of the OB log entry, dated 1/11/17 at 2:15 am, revealed Patient #20, with an estimated due date of 1/7/17 presented to the ED registration desk for possible onset of labor and cramping.

Further review, revealed the nurse contacted the MD at 4:50 am and telephone orders were received to "Discharge home and F/U as needed ..."

In addition, the following was revealed "Diagnosis: False Labor-undelivered." No documented MSE by MD.


OB Patient #21

Review of the OB log entry, dated 6/8/17 at 3:00 pm, revealed Patient #21, with an estimated due date of 6/3/17, presented to the ED registration desk for possible onset of labor and cramping.

Further review, revealed the nurse contacted the MD at 4:50 am and telephone orders were received to "Discharge home and F/U as needed ..."

In addition, the following was revealed "Diagnosis: False Labor-undelivered." No documented MSE by MD.



OB Patient #22

Review of the OB log entry, dated 2/16/17 at 5:06 pm, revealed Patient #22, with an estimated due date of 3/18/17, presented to the ED registration desk for decrease fetal movement.

Further review, revealed the nurse contacted the MD at 5:58 pm and telephone orders were received for an OB ultrasound.
Review of the Ultra Sound transcription, dated 2/16/17 at 5:58 pm, revealed fetal demise.

In addition, the following was revealed "Diagnosis: Fetal demise per U/S." No documented MSE by MD.


During an interview on 7/26/17 at 12:35 pm, the OB Manager stated the OB patients present to the Nurses Desk/ED registration desk if they are requesting a labor exam. The registration staff notifies the OB RN on-call. The OB RN then takes the patient to the OB area and completes a labor assessment and notifies the MD on-call of the findings of the exam. If the MD is needed they would respond at that time. If the OB RN determines the woman is in false or early labor, discharge instructions are given per protocol to follow up with their MD or return with any changes, after consulting with the MD on the telephone.


During an interview on 7/27/17 at 8:45 am the Acute Care Manager stated the ED patients present to the nurses Desk/ED registration desk. The RN then takes the patient to the ED for a triage assessment based on the chief complaint, then per policy the RN can do an EMTALA discharge after contacting the MD on call for the ED.


Review of the "Emergency Department Physician Coverage" policy, dated 5/09, revealed "Emergency Medical Staff coverage will be provided on a 24 hour basis (0800-0800). There will be a physician "On-Call" at all time for all patients who present for care to the Emergency Department."


Review of the "Triage" policy, dated 5/2017, revealed "Obstetrical patients presenting with an obstetrical chief complaint will be seen and evaluated in the OB department by the on call OB provider."