Providence Alaska Medical Center

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 42377 . Based on observation, interview and record review, the facility failed to ensure an acceptable level of safety and quality of the code cart (containing emergency equipment, supplies and medication) was maintained in the Labor and Delivery (L&D) unit. Specifically, the facility failed to ensure one code cart out of one code cart in the L&D unit was checked per facility’s schedule. This failed practice had the potential to place all patients in the L&D unit at risk of not receiving emergency care. Findings: During an observation with concurrent interview on 10/23/24 at 10:20 AM, revealed the L&D unit had one code cart. The Assistant Nurse Manager (ANM) stated the charge nurse was responsible to check the code cart once in every 24 hours. The ANM showed the checklist with incomplete checked dates. The ANM stated the code cart should have been checked every 24 hours. Review of the facility’s “Code Cart Checklist,” dated 10/2024, revealed, the items to be checked were: “All locks Intact,” “Check Exp[expiration] date on Outdate Card & write Date below,” “BVM [Bag Valve Mask] back board present,” “No expired pads, electrodes, ‘transport meds,’” “paper & cables present,” “O2 tank full/Suction tested, (unplugged first),” “Auto defib [defibrillator] Tests OK,” “Weekly Manual Defib & Pacer check complete,” and “Cart cleaned weekly.” Review of the facility’s “Code Cart Checklist,” from April to October 2024, revealed the code cart was not checked every 24 hours on the following dates: 4/7/24, 4/13/24, and 4/25/24, with a total of three days; 5/3/24, 5/12/24, and 5/30/24, with a total of three days; 6/12/24, 6/17/24, and 6/26/24, with a total of three days; 7/19/24, 7/26/24 and 7/31/24, with a total of three days; 8/3/24, 8/10/24, 8/14/24, 8/20/24 and 8/26/24, with a total of five days; 9/1/24, with a total of one day; 10/1/24, 10/6-7/24, 10/9/24, and 10/22/24, with a total of five days. Further review revealed the manual defibrillator was not checked and code cart was not cleaned weekly on 8/8/24, and 10/22/24. During an interview on 10/24/24 at 11:26 AM, the Program Manager Regional Accreditation, confirmed there was only one code cart for the L&D unit. During an interview on 10/24/24 at 12:30 PM with the Quality and Risk Director, when asked about code cart not being checked, he stated it “breaks my heart, sad to hear” and he had “nothing to say.” He further stated “corrective actions” had been started, and he was not sure if it was the only code cart that was not checked. Review of the facility’s “Code Cart, Guidelines for Exchange and Checking” Policy, dated 7/2023, revealed: “This guideline specifies the areas of responsibility for maintenance of emergency equipment in the patient care units and defines the minimum emergency equipment kept in the hospital areas. . . Code Cart: cart containing emergency equipment, supplies and medications. . . Departmental responsibilities . . . at least once per day the integrity of the code cart is checked. . . The defibrillator is checked per competency, defibrillator pads are stored with the defibrillator, and integrity of the red and yellow locks are checked. . .” .”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to follow the provider’s agreement to comply with special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to accept, in a timely manner, an appropriate transfer requiring specialized capabilities for 1 patient (#31), out of 3 transferred patients reviewed. This failed practice delayed care and had the potential to place the patient at risk for complications and delayed recovery. Findings: Patient #31 Record review on 9/6/24 and 9/9-11/24 revealed Patient #31 presented to the Alaska Regional Hospital (ARH) emergency department (ED) on 8/29/24 at 7:20 pm by ambulance with two lacerations, estimated at 4-inches in length each, to the front (anterior) on his/her neck. During an interview on 9/9/24 at 1:20 PM, ARH ED Physician #8 stated at the time Patient #31 presented to the facility, there was no Ear, Nose, and Throat (ENT) specialty available within the hospital. Because of the extent of the trauma, ARH ED Physician #8 initiated a request, through the transfer center call line, for an expedited transfer to Providence Alaska Medical Center (PAMC) for treatment as they had ENT specialty available. ARH ED Physician #8 further stated he/she completed a chest x-ray and CT angiogram (CTA - medical imaging that uses x-rays and special dye to create detailed pictures of blood vessels and tissues of the body), and at the time of contacting the transfer center call line, the CTA imaging results were not back yet. ARH ED Physician #8 further stated there was resistance from PAMC’s ENT physician to accept the transfer, requested imaging results and photos prior to making a decision, and then questioned ARH’s ability to handle the case themselves. Due to this interaction, ARH ED Physician #8 included hospital administration, and after the administration talked with PAMC the transfer was accepted. Review of the transfer center call line’s audio recordings of the phone calls between ARH and PAMC, dated 8/29/24 and provided by ARH, revealed ARH ED Physician #8 was connected with PAMC ED Physician #16 who stated he/she would accept the patient assuming PAMC ENT Physician #24 was in agreement. Further review revealed: 1. ARH ED Physician #8 was able to talk directly to PAMC ENT Physician #24. ARH ED Physician #8 gave a report on the extent of the injury, expressed concerns that this wound was deep enough to expose subcutaneous fat layers and he/she had concerns it may have gone deeper into neck structures, declared ARH did not have the capabilities to treat this injury, and requested transfer to PAMC for treatment. 2. PAMC ENT Physician #24 stated, “basically it is just a cut to the neck” and asked if surgery was available at ARH. ARH ED Physician #8 stated ARH did have general surgery but felt this wound may require ENT specialty if surgical repair was necessary. PAMC ENT Physician #24 asked how deep the cuts were, ARH ED Physician #8 offered to send pictures if it was needed to gain approval, PAMC ENT Physician #24 requested the pictures. After reviewing the pictures, PAMC ENT Physician #24 stated he/she couldn’t tell how deep the cuts were, and ARH ED Physician #8 stated he/she did not feel comfortable exploring the wound which could cause more damage. 3. PAMC ENT Physician #24 requested the CTA imaging results be forwarded for his/her review prior to accepting the transfer. ARH ED Physician stated he/she would send the imaging to PAMC. Review of PAMC’s documentation of the timeline for the phone conversations between the physicians, dated 8/29/24, revealed the following timeline: - 8:00 pm: First call from ARH to transfer center requesting transfer for Patient #31 to PAMC. - 8:03 pm: PAMC ED Physician #16 agreed to accept Patient #31 to the ED assuming PAMC ENT Physician #24 was agreeable. - 8:13 pm: ARH ED Physician #8 was connected with PAMC ENT Physician #24, photos of wounds sent, CTA imaging requested. - 8:26 pm: The CTA imaging for Patient #31 was available for PAMC ENT Physician #24 to review. - 8:40 pm: PAMC ENT Physician #24 notified the transfer center he/she was reviewing the imaging. - 9:26 pm: Review of documentation revealed: “. . . Providers connected at this time. Disagreement as to if patient requires transfer to ENT. [ARH ED Physician #8] uncomfortable closing neck wound therefore requesting transfer. [PAMC ENT Physician #24] aware patient will be transferring to the ER [Emergency Room] . . .” - 9:32 pm: PAMC ED Physician #16 accepted Patient #31 for transfer. (1 hour and 32 minutes after initial request for transfer) During an interview on 9/11/24 at 12:28 pm, the Medical Director state it was the expectation of the facility to ask two questions when ED to ED transfers is requested due to specialty needs: 1. Do we have the capability to treat the patient? and 2) Do we have the capacity, or room, to accept the patient? The Medical Director stated if the answer is yes to both, then we should be accepting patients with every transfer request. When asked about the incident with Patient #31 and PAMC ENT Physician #24 delay in accepting the transfer, the Medical Director stated it wasn’t PAMC ENT Physician #24’s job to determine if ARH had the capability to handle Patient #31’s needs, it was his/her job to accept the transfer and treat the patient. The Medical Director further stated PAMC ENT Physician #24 should not have waited for the imaging before accepting Patient #31’s transfer. Review of the facility’s policy “Emergency Medical Treatment and Labor Act (EMTALA),” effective 4/2024, revealed: “. . . Transferring requirements. If the hospital does not have the capability to treat the condition, and “appropriate” transfer of the patient to another hospital must happen consistent with EMTALA regulations. A hospital with specialized capabilities is obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions . . . Receiving hospital requirements. The receiving facility must have adequate space, equipment, and qualified personnel to treat the individual before agreeing to accept the transfer, the receiving facility is obligated to provide appropriate medical treatment . . .” Review of PAMC ENT Physician #24’s “Reappointment Application for Medical Staff [and] Allied Health Professionals,” dated12/4/22, revealed: “I have had an opportunity to read and will abide by the Hospital and Medical Staff Bylaws, rules and regulations, policies and procedures provided . . . I agree to provide for continuous care of my patients and may be required to take Emergency Room Call in my specialty . . .” .”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to accept, in a timely manner, an appropriate transfer requiring specialized capabilities for 1 patient (#31), out of 3 transferred patients reviewed. This failed practice delayed care and had the potential to place the patient at risk for complications and delayed recovery. Findings: Patient #31 Record review on 9/6/24 and 9/9-11/24 revealed Patient #31 presented to the Alaska Regional Hospital (ARH) emergency department (ED) on 8/29/24 at 7:20 pm by ambulance with two lacerations, estimated at 4-inches in length each, to the front (anterior) on his/her neck. During an interview on 9/9/24 at 1:20 PM, ARH ED Physician #8 stated at the time Patient #31 presented to the facility, there was no Ear, Nose, and Throat (ENT) specialty available within the hospital. Because of the extent of the trauma, ARH ED Physician #8 initiated a request, through the transfer center call line, for an expedited transfer to Providence Alaska Medical Center (PAMC) for treatment as they had ENT specialty available. ARH ED Physician #8 further stated he/she completed a chest x-ray and CT angiogram (CTA - medical imaging that uses x-rays and special dye to create detailed pictures of blood vessels and tissues of the body), and at the time of contacting the transfer center call line, the CTA imaging results were not back yet. ARH ED Physician #8 further stated there was resistance from PAMC’s ENT physician to accept the transfer, requested imaging results and photos prior to making a decision, and then questioned ARH’s ability to handle the case themselves. Due to this interaction, ARH ED Physician #8 included hospital administration, and after the administration talked with PAMC the transfer was accepted. Review of the transfer center call line’s audio recordings of the phone calls between ARH and PAMC, dated 8/29/24 and provided by ARH, revealed ARH ED Physician #8 was connected with PAMC ED Physician #16 who stated he/she would accept the patient assuming PAMC ENT Physician #24 was in agreement. Further review revealed: 1. ARH ED Physician #8 was able to talk directly to PAMC ENT Physician #24. ARH ED Physician #8 gave a report on the extent of the injury, expressed concerns that this wound was deep enough to expose subcutaneous fat layers and he/she had concerns it may have gone deeper into neck structures, declared ARH did not have the capabilities to treat this injury, and requested transfer to PAMC for treatment. 2. PAMC ENT Physician #24 stated, “basically it is just a cut to the neck” and asked if surgery was available at ARH. ARH ED Physician #8 stated ARH did have general surgery but felt this wound may require ENT specialty if surgical repair was necessary. PAMC ENT Physician #24 asked how deep the cuts were, ARH ED Physician #8 offered to send pictures if it was needed to gain approval, PAMC ENT Physician #24 requested the pictures. After reviewing the pictures, PAMC ENT Physician #24 stated he/she couldn’t tell how deep the cuts were, and ARH ED Physician #8 stated he/she did not feel comfortable exploring the wound which could cause more damage. 3. PAMC ENT Physician #24 requested the CTA imaging results be forwarded for his/her review prior to accepting the transfer. ARH ED Physician stated he/she would send the imaging to PAMC. Review of PAMC’s documentation of the timeline for the phone conversations between the physicians, dated 8/29/24, revealed the following timeline: - 8:00 pm: First call from ARH to transfer center requesting transfer for Patient #31 to PAMC. - 8:03 pm: PAMC ED Physician #16 agreed to accept Patient #31 to the ED assuming PAMC ENT Physician #24 was agreeable. - 8:13 pm: ARH ED Physician #8 was connected with PAMC ENT Physician #24, photos of wounds sent, CTA imaging requested. - 8:26 pm: The CTA imaging for Patient #31 was available for PAMC ENT Physician #24 to review. - 8:40 pm: PAMC ENT Physician #24 notified the transfer center he/she was reviewing the imaging. - 9:26 pm: Review of documentation revealed: “. . . Providers connected at this time. Disagreement as to if patient requires transfer to ENT. [ARH ED Physician #8] uncomfortable closing neck wound therefore requesting transfer. [PAMC ENT Physician #24] aware patient will be transferring to the ER [Emergency Room] . . .” - 9:32 pm: PAMC ED Physician #16 accepted Patient #31 for transfer. (1 hour and 32 minutes after initial request for transfer) Review of Patient #31’s ARH ED note, dated 8/29/24, revealed: “. . . Trauma alert called. CT angiogram of the neck performed. Chest x-ray performed and negative for any acute abnormality . . . exams performed in the ER . . . I eventually was able to speak with ENT, [PAMC ENT Physician #24], regarding the case however they wanted further testing before accepting the admission which I feel delayed care . . .” Review of Patient #31’s PAMC ED notes, dated 8/29/24 revealed Patient #31 arrived in their ED at 11:34 pm, and the PAMC ED Physician #52 assumed care. Review of Patient #31’s PAMC ED Physician #52’s note, dated 8/29/24, revealed: “. . . Two lacerations to the anterior neck approximately 8 centimeters in length [3.15 inches] each . . . ENT made aware of patient’s arrival; [PAMC ENT Physician #24] came to evaluate the patient at bedside and kindly agreed to repair the wounds . . .” During an interview on 9/11/24 at 12:28 pm, the Medical Director state it was the expectation of the facility to ask two questions when ED to ED transfers is requested due to specialty needs: 1. Do we have the capability to treat the patient? and 2) Do we have the capacity, or room, to accept the patient? The Medical Director stated if the answer is yes to both, then we should be accepting patients with every transfer request. When asked about the incident with Patient #31 and PAMC ENT Physician #24 delay in accepting the transfer, the Medical Director stated it wasn’t PAMC ENT Physician #24’s job to determine if ARH had the capability to handle Patient #31’s needs, it was his/her job to accept the transfer and treat the patient. The Medical Director further stated PAMC ENT Physician #24 should not have waited for the imaging before accepting Patient #31’s transfer. During an interview on 9/11/24 at 3:13 PM, PAMC ED Physician #52 stated when he/she initially examined Patient #31’s lacerations, he/she wasn’t sure if he/she would have been comfortable closing the wound and was grateful PAMC ENT Physician #24 completed the closure. During an interview on 9/11/24 at 3:18 PM, PAMC ENT Physician #24 stated after he/she reviewed Patient #31’s CTA imaging, he/she felt the laceration was a single skin layer cut and he/she didn’t understand why ARH couldn’t close up the lacerations. PAMC ENT Physician #24 further stated he/she felt the transfer was inappropriate but after talking with ARH’s administration agreed to accept the transfer. Review of PAMC ENT Physician #24’s note, dated 8/30/24, revealed: “. . . Outside imaging did not demonstrate any violation of the platysma [neck muscles] or injury to any neurovascular structures of the head neck. The team there did not feel comfortable suturing up the lacerations and [he/she] was transferred in by ambulance . . . There were repaired in the emergency department without trouble . . . Lacerations were then closed . . . total length of closure was just over 30 cm [11.8 inches] . . .” Review of the facility’s policy “Emergency Medical Treatment and Labor Act (EMTALA),” effective 4/2024, revealed: “. . . Transferring requirements. If the hospital does not have the capability to treat the condition, and “appropriate” transfer of the patient to another hospital must happen consistent with EMTALA regulations. A hospital with specialized capabilities is obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions . . . Receiving hospital requirements. The receiving facility must have adequate space, equipment, and qualified personnel to treat the individual before agreeing to accept the transfer, the receiving facility is obligated to provide appropriate medical treatment . . .” Review of PAMC ENT Physician #24’s “Reappointment Application for Medical Staff [and] Allied Health Professionals,” dated12/4/22, revealed: “I have had an opportunity to read and will abide by the Hospital and Medical Staff Bylaws, rules and regulations, policies and procedures provided . . . I agree to provide for continuous care of my patients and may be required to take Emergency Room Call in my specialty . . .” .”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 42377 . Based on record review and interview, the facility failed to ensure that arrangements from a discharge plan evaluation were made for 1 patient (#1), out of 10 patients reviewed. Specifically, the primary nurse failed to inform the Assisted Living facility (ALF) before the patient was discharged out of the facility through a public transportation (taxi). This failed practice placed the patient at risk for inability to care for himself/herself and exposure to cold weather which may have resulted in cold-related injuries, hypothermia, and/or death. Findings: Record review on 1/22-23/24 revealed Patient #1 was admitted to the facility with diagnoses that included acute COVID (coronavirus) infection without pulmonary involvement, generalized weakness, and dementia (loss of cognitive functioning). Review of Patient #1’s “Discharge Summary,” dated 12/17/23 at 12:04 PM, revealed: “ ... [Patient #1] 84-year-old ...with dementia, normally resides at assisted living facility, was brought to the emergency room for evaluation for generalized weakness. Found to have COVID infection ...Patient was admitted to the hospital for care as there was concern that the assisted living facility cannot take him/her back at his present level of functioning ...Discussion with assisted living facility, they are able to accept patient on Sunday at discharge, even with active COVID precautions ...Discharge Instructions [:] 1. Patient discharged back to assisted living facility ...” Patient Transportation Review of Patient #1’s “Plan of Care,” dated 12/17/23 at 1:34 PM, revealed: “Case Manager [CM #1] requested Navigator’s assistance to provide wheelchair transportation for Patient [’] s discharge to ...[ALF].” The plan of care also revealed the Navigator called “BAC” and “Waymakers” [both are transportation companies]” but there was no opening for “BAC” that day and “Waymakers” was closed. Further review of the plan of care revealed: “ ...Navigator consulted ... [CM #1], who stated Patient [#1] is able to take a Yellow Taxi.” During an interview on 1/22/24 at 2:00 PM, Licensed Nurse (LN) #1 explained the hospital’s discharge process. He/she stated after confirming the availability of the transportation service to be used for patient’s discharge, the discharge nurse would call the receiving facility to verify if they were ready to accept the patient. If the ALF confirmed that they would accept the patient, the discharge nurse would start the discharge paperwork and patient education. Then, the patient would be transferred to the Discharge Lobby (where patient’s wait for their transportation) or to patient’s preferred transportation. During an interview on 1/22/24 at 2:37 PM, CM #2 stated transportation arrangements could have been by private car, van, ground transportation such as taxi, or Lyft [another type of ground transportation utilized by the hospital]. He/she stated he/she would be reluctant to use taxi or Lyft for patient who will go to an ALF. Review of the Discharge Lobby camera video recording, dated 12/17/23 between 2:17 PM to 2:22 PM, revealed Patient #1 was in a wheelchair, wearing a long white sleeve shirt, gray sweatpants, yellow socks, and black shoes. Patient #1 was wheeled out of the facility by 2 hospital staff (unidentified) and transferred to a yellow taxi. Further review of the video recording revealed the yellow taxi left at 2:22 PM. Review of the Patient #1’s “Plan of Care,” dated 12/17/23 at 1:05 PM, revealed: “ ...Patient discharged safely to care facility [,] transportation mode: wheelchair to taxi ...Care timeline ...12/17[/23] Discharged 1422[.]” Hospital’s discharge communication process to receiving care facility During a joint interview on 1/22/24 at 2:37 PM with CM #2 and Social Services Staff, when asked about the communication process between the hospital and the receiving facility, CM #2 stated for a Skilled Nursing facility (SNF), the nurse would have called the SNF nurse before discharge. The CM added it would have been the same process for a patient who would be returning to an ALF. The nurse would have communicated the patient’s discharge information including the date and time of discharge to the ALF. The CM stated the ALF would not call back the hospital unless there was a problem or issue. CM #2 further stated it was not the CM’s role to follow-up with the nurse whether the nurse called the ALF or not. After the discharge process, the CM would have completed a discharge narrative report and his/her role with that patient’s discharge was completed. Review of “Case Management Discharge Summary,” dated 12/17/23 at 9:29 AM, revealed: “ ...Steps taken Towards Discharge: 1130-CM [#1] called ...ALF again and spoke with admin [administrator] who states that it is fine for ...[Patient #1] to return today ... requests that bedside [registered nurse] please update ... on how long patient needs to be in isolation for COVID and when [he/she] leaves in the taxi so that they know when to expect ...[Patient #1] home. Patient care team updated ... above.” During an interview on 1/23/24 at 9:43 PM, CM #1 stated he/she did not know if the primary nurse called the ALF before Patient #1’s discharge. The CM stated he/she expected the nurse would have done what was asked of him/her to do. The CM further stated it was not his/her responsibility to call the ALF if the patient discharged safely. During an interview on 1/23/24 at 12:30 PM, LN #3, who discharged the patient on 12/17/23, stated the patient had dementia but he/she would not know the level of the patient’s condition without cognitive evaluation. LN #3 stated the patient was able to follow instructions during the discharge process. LN #3 recalled that the patient needed shoes and he/she picked-up shoes from “Claire’s” (where donated clothing for patients who needed clothes were stored). The LN added Patient #1 wore regular clothing before discharge. During the same interview, when asked if he/she called the ALF before discharge as requested in the Case Management Discharge Summary, dated 12/17/23 (the document was shown to LN #3), LN #3 stated after he/she called for patient’s transfer from patient’s room to the discharge lobby, he/she “got busy on something” and went for a lunchbreak. LN #3 added he/she remembered during his/her lunchbreak that he/she did not call the ALF. LN #3 stated he/she called ALF and left a voicemail later that afternoon. He/she could not remember if ALF returned the call. When asked if he/she was trained to call the ALF after patient discharge, LN #3 stated “nobody said anything to coordinate somebody to get home.” When asked if there was documentation of the call made to ALF, he/she stated he/she documented it in the medical record, but the LN could not find the note in EPIC (the hospital’s electronic health record). While the LN was checking his/her EPIC account, LN #3 remembered that he/she send a text message to CM #1 through the hospital’s secure text messaging system. Review of LN #3’s text message, dated 12/17/23 at 3:07 PM, revealed: “ ...I just got a chance to call them, I apologize[.]” “went to voicemail[.]” Review of the State of Alaska (AK) Health Facilities Licensing and Certification complaint “Intake Information,” AK #00004480, revealed: on “12/17/23 at 3:30 PM, Staff found ... [Patient #1] out on the driveway. Temperature 35 degrees with excessive snow accumulation this year (>70 inches).” Further review of the intake information revealed Patient #1 was “ ... on the ground, with no jacket ...” outside the ALF. Review of the hospital’s “Discharge of Patient Process,” dated 11/2023, revealed: “ ...Attachment A: Provider and Hospital Caregiver responsibilities ...On the day of discharge, the nurse calls the designated caregiver to inform them of the patient’s discharge order. If the nurse cannot make the phone call, the caregiver call is delegated to the charge nurse. The phone call to the designated caregiver is documented in EPIC ...” .”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40259 . 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. .”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 40259 . 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. .”