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.

PROVIDENCE ALASKA MEDICAL CENTER 3200 PROVIDENCE DRIVE ANCHORAGE, AK 99508 May 9, 2018
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review, interview, and patient rights review, the facility failed to inform 1 patient's (#9) representative who was involved in the patient's care; of a transfer within the hospital, out of 11 patient records reviewed. Specifically, the facility's failure to inform the representative of the transfer within the hospital caused the spouse of the patient, emotional distress. Findings:

Record review on 5/8-9/18 revealed Patient #9 was admitted to the facility on [DATE] with a diagnosis of aspiration pneumonia.

During an interview on 5/8/18, a family member stated Patient #9 was in the ACCU (Adult Critical Care Unit) for 3 weeks. The family member stated the Patient was transferred on 5/7/18 during the middle of the night. The family member also stated the Patient's spouse, who was listed as the designated caretaker, was not notified of the transfer and arrived at the hospital at approximately 7:30 am on 5/7/18 to discover the Patient was not in his/her room.

Record review on 5/8-9/18 of the electronic medical record (EMR) revealed a "Plan of Care" nurse's note dated 5/6/18 at 6:29 pm, in the ACCU. Additionally, a "Plan of Care" nurse's note on the IMCU (Inpatient Medical Critical Care Unit) dated 5/7/18 at 4:35 am, revealed "...Restarted TF [tube feeding]...at 0030 [3:00 am]..."

During an interview on 5/9/18 at 10:30 am Staff #1, stated the facility did not consistently report to the family. Staff #1 also stated the goal was not to move people that late at night, however, she said it would be nice if they notified the family, but they didn't have to.

During an interview on 5/9/18 at 11:00 am, the Clinical Manager of the IMCU stated the expectation would be for the designated caregiver to be notified of the transfer.

During an interview on 5//9/18 at 1:05 pm, Staff #2, stated there was no other documentation regarding notifying the designated caregiver in the EMR.

Review of the Patient Rights & Responsibilities, provided to patients on admission, revealed "As a patient at Providence Alaska Medical Center you have the right to...Make decisions about your care to include, or exclude, family members or others when making decisions."

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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
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Based on record review and interviews the facility failed to ensure measures to protect patients from potential abuse and/or neglect were implemented for 1 patient (#12) out of 2 patients with allegations reviewed. Specifically, the facility failed to ensure: 1) an incident was communicated immediately to administration by facility staff; 2) the incident was reported to the State agency; and 3) measures to protect patients were implemented. This failed practice created a risk for further abuse and/or neglect of all patients utilizing the facility. Findings:

Communication:

Record review on 5/9/18 revealed an investigation report of potential exploitation towards Patient #12 by Physician #1. Further review revealed the incident was not reported to facility administration until 7 days after the event.

During an interview on 5/9/18 at 9:30 am, when asked about the delay in reporting Director of Patient Safety (DPS) and the Director of Risk and Legal Claims (DRLC) stated the caregivers that had witnessed the incident were off work for several days, they then returned to work and decided to report it.

When asked if any extra education regarding abuse and neglect had been provided to facility staff, the DRLC stated "no."

Review of the facility policy "Protection of Vulnerable Adults from Abuse, Neglect, and Exploitation", review date 3/2017, revealed "Any circumstance in which there is reasonable cause for suspicion is reported in 24 (twenty-four) hours."

Review of the Mandated Reporting education, provided to facility staff, revealed "It is the policy of Providence to ..."Patient abuse by a healthcare provider is a breach of medical ethics ..." Further review of the education slides revealed no designated timelines for reporting potential and/or actual abuse and/or neglect.


Reporting to State Agency

During an interview on 5/9/18 at 9:30 am, when asked if the event with Patient #12 had been reported to the State agency, the DPS and DRLC stated "[incident] was reported to the local police."

Record review of the facility sexual abuse policy, last reviewed 12/20/17, revealed "If there is reasonable cause to believe that sexual abuse of a dependent adult...has occurred, the governing regulatory agencies for the specific ministry must be contacted. The Administrator/AOC is responsible for ensuring that the incident is reported to the applicable regulatory agencies such as the State of Alaska Department of Health and Social Services (Health Facilities Licensing and Certification and/or Adult Protective Services)..."

Further review of policies for Sexual Abuse and Protection of Vulnerable Adults from Abuse, Neglect, and Exploitation revealed no process for reporting incidents to applicable professional licensing authorities.


Patient Protection

During an interview on 5/9/18 at 9:30 am, when asked how the protection and safety of all patients were ensured after an allegation of abuse, the Medical Staff Program Director stated the #1 priority is to ensure the patients are safe and if something had happened they would suspend the provider right away. When asked how patients are protected during the investigation, the Medical Staff Program Director stated they would interview the provider and get his/her point a view. When asked about the case with Patient #12, the Medical Staff Program Director stated the facility had not suspended Physician #1's privileges or implement an "escort" (second party to witness procedures) protocol. She stated the facility developed a "performance improvement plan" for the physician.

The performance improvement plan was not provided to surveyors.

Interview on 5/9/18 at 9:30 am, when asked if staff received additional training on timelines and circumstances for reporting potential abuse, the DRLC stated "No."

Interview on 5/9/18 at 9:30 am, when asked about the process for reviewing complaints against physician's the DRLC stated "employed caregivers, I can work with, not credentialed." The DRLC stated any allegations involving physicians would be reported to Medical Executive Committee for review.

A record review of Medical Staff By-laws revealed an absence of clear process for the protection of vulnerable patient's during and after an allegation of inappropriate sexual conduct or abuse by a physician. In contrast, a review of PAMC Sexual Abuse policy reveals "The accused employee shall be placed on administrative leave pending completion of the investigation."

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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on record review and interview the facility failed to ensure physician orders for restraints were written for the appropriate age criteria for 3 (#s 7; 10; and 11) out of 3 adolescent patients reviewed. This failed practice placed patients at a vulnerable age at risk for injury and/or harm for being restrained longer than appropriate. Findings:


Patient #7

Record review on 5/9/18 revealed a [AGE] year old Patient was seen in the facility's ED psychiatric observation for suicidal ideation.

Review of the physician's orders, dated 3/8/18, revealed two orders for the Patient, the "Restraint child [with] violent behavior (order 8130)...Continuous x 1 hour...This order to be used on a patient under the age of 9 years" and "Restraint adult [with]violent behavior (order 807)...continuous x 4 hours....This order used on a patient 18 years and older."


Patient #10

Record review on 5/9/18, revealed Patient #10, a [AGE] year-old, seen in the facility's Emergency Department (ED) psychiatric observation for suicidal observation.

Review of the physician orders, dated 3/30/18, revealed an initial Restraint order for patients aged 9-17 years with a 2 hour time limit on restraints. That order was discontinued and a "Restraint Adult [with] Violent Behavior (order 523)" was ordered. Under order details "...frequency...continuous x 4 hours...this order to be used on a patient 18 years and older."


Patient #11

Record review on 5/9/18 revealed Patient #11 was a [AGE] year-old seen in the facility's ED psychiatric observation for acute psychosis.

Review of a nurses note, dated 2/19/18 at 4:03 pm, revealed "Patient placed in restraints to prevent significant harm to self or others. Pt attempting to bite staff while being placed in restraints." Patient #11 was released from the restraints at 4:42 pm.

Review of a physician's order, dated 2/19/18, revealed "Restraint Adult [with] Violent Behavior (order 388)...frequency...continuous x 4 hours...this order to be used on a patient 18 years and older."

During an interview on 5/9/18 at 3:58 pm, the Director of Emergency Services (DES), upon speaking with Physician #2, stated restraint orders only showed up as violent behavior as non-violent. The DES stated even if the correct age set was chosen it would be deleted when the restraints for violence were ordered due the programming in Epic (electronic record).

Review of the facility policy 'Restraint Management, Attachment B', reviewed 2/2017, revealed a "Restraint Guideline Summary" for Violent or destructive behavior...Time limit for restraint order...4 hours adults; 2 hours ages 9-17; 1 hour ages <9 ".

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