Alaska Native Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 51613 51615 . Based on record review and interview, the facility failed to ensure restraint use was reassessed and discontinued at the earliest possible time for 1 patient (#25) out of 1 patient reviewed for restraint use. Specifically, the facility initiated bilateral mitt restraints for Patient #25 after the patient attempted to remove a Rhino Rocket (a compressed, expandable sponge inserted into the nasal cavity and inflated or moistened to apply direct pressure to the nasal mucosa to achieve hemostasis) but failed to document that staff reassessed the patient’s restraint status before discharge, determined whether the unsafe situation continued, or determined whether the restraints could be safely discontinued before transport from the Emergency Department (ED). This failed practice resulted in Patient #25 being discharged from the ED while still in bilateral mitt restraints, without documentation that the restraints remained medically necessary during transport. This placed Patient #25 at risk for unnecessary restriction of movement, injury, unmet care needs, loss of dignity, and continued restraint use without medical oversight. Findings: Record review of “Adult Protective Services Intake Report,” dated 4/20/26, revealed: “ ... received a report from the ALH [Assisted Living Home] that [Patient #25] ... the morning on 4/19[26] ... [Patient #25] had returned back to the ALH after being at ANMC ER [Alaska Native Medical Center Emergency Room]. [Patient #25] has been admitted at [originating facility] since 4/3[26] after experiencing a stroke ... [He/she] was reported to have a nosebleed that started late in the evening on 4/18[26]. Once [originating facility] was unable to get it to stop after an extended period of time they called EMS [Emergency Medical services] and had [him/her] transported to ANMC ER for treatment. [Patient #25] was supposed to return back to [originating facility name] as [he/she] is still considered a patient there and has not yet discharged, but was sent home to [his/her] ALH by ANMC ...The home did not know [he/she] was returning and had not spoken to anyone in regard to this ... The ALH was unaware [he/she] was returning home, how to care for [him/her] at this time during [his/her] recovery from [his/her] stroke, why [he/she] had a tube coming out of [his/her] nose, and why [he/she] was in restraints which is not allowed in an assisted living home”. Record review on 4/23/26 of “ED Clinical Summary,” revealed Patient #25 was admitted to the Alaska Native Medical Center’s ED on 4/18/26 for a chief complaint of epistaxis (nosebleed). Record review of “ED Provider Note,” dated 4/19/26, revealed the course of Patient #25’s ED visit: “ ...Placed 5 cm [centimeter] Rhino Rocket but patient shortly after placing removed. Due to continuing to ooze and on Plavix [clopidogrel is an antiplatelet medication used to prevent blood clots] he was given 0.5 mg [milligrams] of Ativan [lorazepam- medication used to treat anxiety]... [he/she] intermittently attempted to remove ... soft mitten restraints were placed.” Review of nursing notes dated 4/19/26 at 4:27 AM, revealed the behavior requiring non-violent restraint was “Pulling at tubes, lines ...” The documentation further revealed the restraint activity was “Initiated,” and “Restraints education and IPOC [interdisciplinary plan of care]” was marked “Yes.” Further review revealed the provider was notified, the restraint order was current, the restraint type was “Non-Violent/Non-Self Destructive,” the restraint device was “Mittens,” and the restraint location was “Bilateral Upper Extremities.” The nursing narrative stated: “mittens placed for rhino rc [rocket]”. Further review of nursing notes did not reveal documentation that nursing staff removed or discontinued the mitten restraints prior to discharge from the ED. The EHS (electronic health system) did not reveal documentation that the restraints were reassessed at discharge, remained medically necessary during transport, or were communicated to and accepted by the receiving ALF. During an interview on 4/23/26 at 3:05 PM, Nursing Director (ND) #1 was asked to describe the facility’s process for discontinuing restraints prior to discharge from the ED. He/she stated, “I’d have to look it up verbatim. I couldn’t speak to that off the top of my head.” When asked whether patients were ever discharged from the hospital while still in restraints, ND #1 stated, “Not typically.” ND #1described Patient #25’s ED course and stated Patient #25 presented with epistaxis (nosebleed), dementia, and a Rhino Rocket in place. ND #1 stated Patient #25 was “trying to remove said rhino rocket continuously,” and “there’s a decision to put on mitts to prevent [Patient #25] from pulling it out.” When asked whether mitts were considered a restraint, ND #1 stated, “I believe so.” When asked at what point in the discharge process restraints should be removed, ND #1 stated, “Ideally ... no one’s in restraints unless there’s a medical need for them before they’re discharged.” When asked who was responsible for ensuring restraints were discontinued prior to transfer, ND #1 stated, “I think nursing and the attending combined.” Review of the facility’s “Restraint Procedure,” last reviewed 11/20/25, revealed: “ ...All patients have a right to be free from restraint or seclusion not medically necessary or imposed as a means of coercion, discipline, convenience, or retaliation by staff ... Restraint or seclusion may only be imposed to ensure the immediate physical or medical safety of the patient, staff member, or others and must be discontinued at the earliest possible time.” The policy defined a physical restraint as: “ ...any manual method, physical or mechanical device, material, or equipment immobilizing or reducing the ability of a patient to move their arms, legs, body, or head freely.” The policy further identified restraints to include: “ ...use of mittens, tied or untied”. The policy further stated: “ ...Restraint must be discontinued at the earliest possible time regardless of the length of time identified in the restraint order.” Review of the facility’s “Patient Right and Responsibilities Policy and Procedure,” last reviewed 3/27/24, revealed: “ ...ANMC recognizes and safeguards patient’s fundamental rights to services that protect their personal dignity ... Policies and procedures will reflect and implement ANMC’s commitment to respect for patient rights and responsibilities ... The institution to which the patient is to be transferred must have accepted the patient for transfer ... The patient has the right to expect reasonable continuity of care ... The patient has the right to a safe environment, which is a priority for the ANMC ... Patients have the right to be free from mental, physical ... neglect ...” .”

“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 implement the protocols established in the facility policy “Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure,” regarding the availability of on-call physicians, for 1 request for transfer received, out of 1 request reviewed. This failed practice placed the patient and the patient’s pregnancy at risk for a delay in emergency medical care. Findings: Incident on 12/23/24 Review of facility-provided recorded phone conversations, from a rural Physician Assistant (PA #4) to the facility’s call center, on 12/23/24, revealed: - At 2:12 AM - PA #4 called the facility’s call center requesting transfer of a woman (Patient #50) who was 30 weeks pregnant and was experiencing contractions and bleeding. The woman had a history of abruption(a serious pregnancy complication where the placenta separates from the uterine wall before delivery. This can cause heavy bleeding and reduce the baby’s supply of oxygen and nutrients). PA #4 further stated he/she had explained that if Patient #50 did deliver, the baby would need a NICU (Neonatal Intensive Care Unit) and that Med Flight was enroute to transport Patient #50. PA #4 requested to talk to an OB provider or if needed, to talk to an ED provider first. Further review revealed Call Center Nurse #19 stated he/she would put PA #4 through to an OB provider. He/she obtained a call back number for PA #4 and stated he/she would call PA #4 back as soon as he/she got a provider on the line. - At 2:34 AM, PA #4 called the facility’s call center back as he/she had not received a return call from an OB provider. Call Center Nurse #19 state he/she would message OB again and he/she would call PA #4 back. - At 2:35 AM, Call Center Nurse #19 called the OB unit of the facility. When a nurse from OB answered, Call Center Nurse #19 asked if an OB provider was available. The nurse from OB stated both providers were “both busy right now.” When Call Center Nurse #19 inquired how long it would be before one was available the nurse from OB stated he/she did not know “our doc is in the OR and our midwife is in a room.” Call Center Nurse #19 ended the call. - At 2:47 AM, Call Center Nurse #19 called PA #4 back. He/she informed PA #4 that both OB providers were busy and asked when flight would be arriving. PA #4 stated flight would be arriving in 50 to 55 minutes. Call Center Nurse #19 asked if Patient #50 was contracting, PA #4 informed him/her that Patient #50 was contracting every 47 seconds. Further review revealed that PA #4 stated that since he/she couldn’t get a hold of a provider he/she may have to just contact a different facility. Call Center Nurse #19 stated he/she thought that was a good plan and PA #4 ended the call. Record review on 12/31/24 revealed the facility had EMS/EMTALA protocols established to use when a provider called the facility, using the facility’s call center, to request transfer to the facility due to medical emergencies and the need for a higher level of care. Review of the facility’s policy “Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure,” last revised 5/1/17, revealed the facility failed to implement the following procedure sections of the policy when PA #4 contacted the facility on 12/23/24 and requested transfer: Policy Section 4.2 Responsibilities of On-Call Practitioners: 1) “. . . 4.2.1 In general, on-call practitioners are expected to respond to pagers and return telephone calls within 15 minutes and to be available on site within 60 minutes if requested by a treating practitioner or designee . . .” During an interview on 12/31/24 at 10:58 AM, the Clinical Nurse Manager (CNM) of the Central Nursing Office (the call center’s manager), stated it was the expectation of all nurses in the call center to connect providers who call with a facility provider. Once connected the facility provider will have a conversation with the provider who called and determine if an admission is warranted or if they should go to a different hospital. The CNM of the Central Nursing Office further stated that when the call center pages or tiger texts (online communication tool) a facility provider, there was a 20-minute call back timeframe for providers. Review of the facility document, “Admitting Notification Worksheet,” the call center’s log of PA #4’s phone contact, dated 12/23/24, revealed On-Call OB Provider #1 was paged on 12/23/24 at 2:15 AM. 2) “. . . 4.2.4 Practitioners who are treating another patient when paged or called must respond within the timeframes established by this or other applicable procedures to inform the attending practitioner when the practitioner can discuss the case with the treating practitioner, consult about the type of care to be provided to the individual until the on-call practitioner can personally attend to the individual of requested, and, if necessary, implement the back-up plan . . .” Review of the call center’s telephone recording on 12/23/24 at 2:35 AM, revealed one OB Provider was in an OR and the midwife was in a room, however, did not clarify what the midwife was doing in the room. Further review revealed Call Center Nurse #19 did not ask if the midwife could step out to speak on the phone. Review of the facility document, “Admitting Notification Worksheet,” dated 12/23/24, revealed no documentation when On-Call OB Provider #1 returned the page to contact the call center. Further review revealed no documentation of a second page for On-Call OB Provider #1. Policy Section 4.4 Alternatives 3) “. . . 4.4 Alternatives: If no practitioner with the needed specialty is on-call or if the on-call practitioner is not available or does not respond or appear within a reasonable time, the treating practitioner may . . . 4.4.2 use other available resources to meet the individual’s needs, including other on-site or on-call practitioners . . .” During an interview on 12/31/24 at 10:58 AM, when asked what the protocol was for the nurses of the call center when the provider didn’t call back, the CNM of the Central Nursing Office stated the nurses would attempt to call back several times, but if that was unsuccessful the nurses would contact an ED doctor to talk to the provider who called. Review of the facility’s on-call schedule dated, 12/22-23/24, revealed two OB/GYN (obstetrics and gynecology) practitioners were on call for 12/22-23/24, On-Call OB Provider #1 and On-Call OB Provider #62. Neither of these providers were a midwife. Further review of the facility document, “Admitting Notification Worksheet,” dated 12/23/24, revealed no documentation to attempt to contact On-Call OB Provider #62. Further review revealed no attempt to contact an ED provider. During an interview on 12/31/24 at 11:30 AM, when asked, because OB provider #1 did not respond to the page on 12/23/24, if Call Center Nurse #19 should have contacted an ED provider, the CNM of the Central Nursing Office stated Call Center Nurse #19 should have connected PA #4 with an ED provider. Policy Section 4.5 Mandatory Reporting 4) “. . . 4.5 Mandatory Reporting: ANMC staff must make the following reports to ensure compliance with the EMS/EMTALA Policy and related procedures and other applicable requirements and to facilitate adequate tracking required for quality and performance improvement processes. 4.5.1 The treating practitioner or designee will promptly report an on-call practitioner’s unavailability, refusal, lack of timely response or appearance and/or the inadequacy of any back up plan to: 4.5.1.1 Relevant [facility] peer review or performance improvement body; and 4.5.1.2 the SCMD [Service Center Medical Directors] (or CMO [Chief Medical Officer] if it is the SCMD who did not respond timely). 4.5.2 The report will be made even if the treating practitioner thinks the circumstances were beyond the on-call practitioner’s control . . .” During an interview on 12/31/24 at 10:58 AM, when asked if there was a protocol the call center nurses used when they were unable to make contact with a provider, the interim Chief Nursing Officer stated the nurses would alert the AOC (Administrator on call) to inform them there was a problem contacting a provider. The AOC would then alert other higher-level leaders and risk management, and they would complete an investigation. During the course of this survey, on 12/31/24, no documentation was found to support the facility’s mandatory reporting protocols were implemented. During an interview on 12/31/24 at 11:33 AM, the interim Chief Nursing Officer stated that after hearing the 12/23/24 recorded phone conversation with PA #4, there was room for improvement in the call center’s actions. Rural Clinic Medical Record Review Review of the rural clinic’s Physician Note for Patient #50, dated 12/23/24, revealed: “. . . I spoke with the ED physician at FMH [Fairbanks Memorial Hospital] and we decided that since the patient seems to be going into labor and the fetus his age was unknown, but had a high likelihood of needing to go to the NICU, we decided that it would be best to send the patient directly to Anchorage. I spoke with the transfer center at ANMC [Alaska Native Medical Center], but both of their OBs on-call were unable to take my calls x 2 due to being in surgery . . .” Review of the facility policy “Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) General Procedure,” last revised 5/1/17, revealed: “ANMC staff will provide an appropriate Medical Screening Examination and necessary stabilizing treatment and/or an appropriate transfer to all individuals at ANMC in accordance with the EMS/EMTALA Policy and related procedures . . .” .”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 40259 . Based on interview and observation, the facility failed to ensure signage informing patients of the Emergency Medical Treatment and Labor Act (EMTALA) was posted at 1 out of 2 entrances to the Emergency Department (ED). This failed practice denied patients access to information about their right to a Medical Screening Exam. Findings: During an interview on 12/31/24 at 8:30 AM, the Manager of the ED stated that there were two entrances into the ED. One was for walk-in patients and the other was for the ambulance personnel to bring patients in on gurneys. An observation on 12/31/24 at 8:30 AM, revealed there was EMTALA signage in the entryway of the walk-in entrance. Further observation revealed there was no EMTALA signage in the entryway of the ambulance personnel/gurney entrance. During an interview on 12/31/24 at 8:52 AM, the interim Chief Nursing Officer stated that signs in the ambulance personnel/gurney entrance were taken down to get framed. Review of the facility’s policy “Emergency Medical Treatment and Labor Act (EMTALA) Policy,” last reviewed 9/7/24, revealed: “. . . ANMC shall post a sign in a conspicuous area(s) of the Emergency Services Department, entrance, admitting areas, waiting room, treatment areas, etc., specifying the rights of the individual with respect to examination and treatment of medical conditions and women in labor . . .” .”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 40259 . Based on record review and interview, the facility failed to implement the protocols established in the facility policy “Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure,” regarding the availability of on-call physicians, for 1 request for transfer received, out of 1 request reviewed. This failed practice placed the patient and the patient’s pregnancy at risk for a delay in emergency medical care. Findings: Incident on 12/23/24 Review of facility-provided recorded phone conversations, from a rural Physician Assistant (PA #4) to the facility’s call center, on 12/23/24, revealed: - At 2:12 AM - PA #4 called the facility’s call center requesting transfer of a woman (Patient #50) who was 30 weeks pregnant and was experiencing contractions and bleeding. The woman had a history of abruption(a serious pregnancy complication where the placenta separates from the uterine wall before delivery. This can cause heavy bleeding and reduce the baby’s supply of oxygen and nutrients). PA #4 further stated he/she had explained that if Patient #50 did deliver, the baby would need a NICU (Neonatal Intensive Care Unit) and that Med Flight was enroute to transport Patient #50. PA #4 requested to talk to an OB provider or if needed, to talk to an ED provider first. Further review revealed Call Center Nurse #19 stated he/she would put PA #4 through to an OB provider. He/she obtained a call back number for PA #4 and stated he/she would call PA #4 back as soon as he/she got a provider on the line. - At 2:34 AM, PA #4 called the facility’s call center back as he/she had not received a return call from an OB provider. Call Center Nurse #19 state he/she would message OB again and he/she would call PA #4 back. - At 2:35 AM, Call Center Nurse #19 called the OB unit of the facility. When a nurse from OB answered, Call Center Nurse #19 asked if an OB provider was available. The nurse from OB stated both providers were “both busy right now.” When Call Center Nurse #19 inquired how long it would be before one was available the nurse from OB stated he/she did not know “our doc is in the OR and our midwife is in a room.” Call Center Nurse #19 ended the call. - At 2:47 AM, Call Center Nurse #19 called PA #4 back. He/she informed PA #4 that both OB providers were busy and asked when flight would be arriving. PA #4 stated flight would be arriving in 50 to 55 minutes. Call Center Nurse #19 asked if Patient #50 was contracting, PA #4 informed him/her that Patient #50 was contracting every 47 seconds. Further review revealed that PA #4 stated that since he/she couldn’t get a hold of a provider he/she may have to just contact a different facility. Call Center Nurse #19 stated he/she thought that was a good plan and PA #4 ended the call. Record review on 12/31/24 revealed the facility had EMS/EMTALA protocols established to use when a provider called the facility, using the facility’s call center, to request transfer to the facility due to medical emergencies and the need for a higher level of care. Review of the facility’s policy “Emergency Medical Services/Emergency Medical Treatment and Labor Act (EMS/EMTALA) On-Call Procedure,” last revised 5/1/17, revealed the facility failed to implement the following procedure sections of the policy when PA #4 contacted the facility on 12/23/24 and requested transfer: Policy Section 4.2 Responsibilities of On-Call Practitioners: 1) “. . . 4.2.1 In general, on-call practitioners are expected to respond to pagers and return telephone calls within 15 minutes and to be available on site within 60 minutes if requested by a treating practitioner or designee . . .” During an interview on 12/31/24 at 10:58 AM, the Clinical Nurse Manager (CNM) of the Central Nursing Office (the call center’s manager), stated it was the expectation of all nurses in the call center to connect providers who call with a facility provider. Once connected the facility provider will have a conversation with the provider who called and determine if an admission is warranted or if they should go to a different hospital. The CNM of the Central Nursing Office further stated that when the call center pages or tiger texts (online communication tool) a facility provider, there was a 20-minute call back timeframe for providers. Review of the facility document, “Admitting Notification Worksheet,” the call center’s log of PA #4’s phone contact, dated 12/23/24, revealed On-Call OB Provider #1 was paged on 12/23/24 at 2:15 AM. 2) “. . . 4.2.4 Practitioners who are treating another patient when paged or called must respond within the timeframes established by this or other applicable procedures to inform the attending practitioner when the practitioner can discuss the case with the treating practitioner, consult about the type of care to be provided to the individual until the on-call practitioner can personally attend to the individual of requested, and, if necessary, implement the back-up plan . . .” Review of the call center’s telephone recording on 12/23/24 at 2:35 AM, revealed one OB Provider was in an OR and the midwife was in a room, however, did not clarify what the midwife was doing in the room. Further review revealed Call Center Nurse #19 did not ask if the midwife could step out to speak on the phone. Review of the facility document, “Admitting Notification Worksheet,” dated 12/23/24, revealed no documentation when On-Call OB Provider #1 returned the page to contact the call center. Further review revealed no documentation of a second page for On-Call OB Provider #1. Policy Section 4.4 Alternatives 3) “. . . 4.4 Alternatives: If no practitioner with the needed specialty is on-call or if the on-call practitioner is not available or does not respond or appear within a reasonable time, the treating practitioner may . . . 4.4.2 use other available resources to meet the individual’s needs, including other on-site or on-call practitioners . . .” During an interview on 12/31/24 at 10:58 AM, when asked what the protocol was for the nurses of the call center when the provider didn’t call back, the CNM of the Central Nursing Office stated the nurses would attempt to call back several times, but if that was unsuccessful the nurses would contact an ED doctor to talk to the provider who called. Review of the facility’s on-call schedule dated, 12/22-23/24, revealed two OB/GYN (obstetrics and gynecology) practitioners were on call for 12/22-23/24, On-Call OB Provider #1 and On-Call OB Provider #62. Neither of these providers were a midwife. Further review of the facility document, “Admitting Notification Worksheet,” dated 12/23/24, revealed no documentation to attempt to contact On-Call OB Provider #62. Further review revealed no attempt to contact an ED provider. During an interview on 12/31/24 at 11:30 AM, when asked, because OB provider #1 did not respond to the page on 12/23/24, if Call Center Nurse #19 should have contacted an ED provider, the CNM of the Central Nursing Office stated Call Center Nurse #19 should have connected PA #4 with an ED provider. Policy Section 4.5 Mandatory Reporting 4) “. . . 4.5 Mandatory Reporting: ANMC staff must make the following reports to ensure compliance with the EMS/EMTALA Policy and related procedures and other applicable requirements and to facilitate adequate tracking required for quality and performance improvement processes. 4.5.1 The treating practitioner or designee will promptly report an on-call practitioner’s unavailability, refusal, lack of timely response or appearance and/or the inadequacy of any back up plan to: 4.5.1.1 Relevant [facility] peer review or performance improvement body; and 4.5.1.2 the SCMD [Service Center Medical Directors] (or CMO [Chief Medical Officer] if it is the SCMD who did not respond timely). 4.5.2 The report will be made even if the treating practitioner thinks the circumstances were beyond the on-call practitioner’s control . . .” During an interview on 12/31/24 at 10:58 AM, when asked if there was a protocol the call center nurses used when they were unable to make contact with a provider, the interim Chief Nursing Officer stated the nurses would alert the AOC (Administrator on call) to inform them there was a problem contacting a provider. The AOC would then alert other higher-level leaders and risk management, and they would complete an investigation. During the course of this survey, on 12/31/24, no documentation was found to support the facility’s mandatory reporting protocols were implemented. During an interview on 12/31/24 at 11:33 AM, the interim Chief Nursing Officer stated that after hearing the 12/23/24 recorded phone conversation with PA #4, there was room for improvement in the call center’s actions. Rural Clinic Medical Record Review Review of the rural clinic’s Physician Note for Patient #50, dated 12/23/24, revealed: “. . . I spoke with the ED physician at FMH [Fairbanks Memorial Hospital] and we decided that since the patient seems to be going into labor and the fetus his age was unknown, but had a high likelihood of needing to go to the NICU, we decided that it would be best to send the patient directly to Anchorage. I spoke with the transfer center at ANMC [Alaska Native Medical Center], but both of their OBs on-call were unable to take my calls x 2 due to being in surgery . . .” Review of the facility policy “Emergency Medical Services and Emergency Medical Treatment and Labor Act (EMS/EMTALA) General Procedure,” last revised 5/1/17, revealed: “ANMC staff will provide an appropriate Medical Screening Examination and necessary stabilizing treatment and/or an appropriate transfer to all individuals at ANMC in accordance with the EMS/EMTALA Policy and related procedures . . .” .”