HospitalInspections.org

Based on policy review, review of hospital security documents, medical record review, and interview, the hospital failed to ensure nursing staff documented in the medical record regarding a patient leaving Against Medical Advice (AMA) for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital policy "Against Medical Advice Policy" revealed, "...PURPOSE: Provide guidelines for when a patient or a patient's legal guardian chooses to leave the hospital Against Medical Advice...POLICY...When a patient leaves Against Medical Advice, the Electronic Medical Record should reflect exactly what treatment and instructions were advised, with thorough documentation...Primary Nurse should Document in the patient's medical record...The patient's desire to leave AMA and specific reasons stated by the patient for leaving...Patient's mental status and objective behavior...Written instructions and recommendations for follow-up given to patient...What efforts were made to prevent the patient from leaving and what attempts were made to secure consent..."

2. Review of hospital security document "SECURITY INCIDENT REPORT" dated 7/5/20 revealed, "AT APPROXIMATELY 1410 HOURS (2:10 PM), SECURITY RESPONDED TO A CODE ATLAS [code for a combative patient] IN [Patient #1's room]. UPON ARRIVAL, SECURITY WAS BRIEFED BY THE CHARGE NURSE THAT THE PATIENT [Patient #1] WAS BEING VERBALLY ABUSIVE TOWARDS THE DOCTOR AND NURSING STAFF. AFTER SEVERAL MINUTES OF DE-ESCALATION ATTEMPTS BY DIFFERENT STAFF, THE PATIENT DECIDED TO LEAVE THE HOSPITAL AMA. SECURITY ESCORTED THE PATIENT TO THE MAIN ENTRANCE TO THE HOSPITAL. NO FURTHER ACTION WAS REQUIRED FROM SECURITY. INCIDENT ENDED WITHOUT INJURY TO THE STAFF OR PATIENT."

3. Medical record review for Patient #1 revealed an admission date of 7/4/2020 with diagnoses which included Palsy and Acute Kidney Injury.

The "Leaving Against Medical Advice (AMA)" form dated 7/5/2020 was signed by Patient #1, Nurse #2, and Nurse #3 at 1:55 PM.

The Discharge Summary dated 7/5/2020 revealed, "...Patient became agitated while admitted and I was informed by the RN [registered nurse] that patient left AMA..."

A Nursing Note dated 7/5/2020 revealed, "Pt [Patient #1] decided to leave AMA. [Physician #1] at bedside and aware of situation. AMA papers signed and pt ambulatory to private car. Belongings sent. Tolerated well. House supervisor at bedside."

There was no documentation of the specific reasons stated by Patient #1 for leaving. There was no documentation of Patient #1's mental status and objective behavior. There was no documentation of written instructions and recommendations for follow-up given to Patient #1 or of the refusal of this information by the patient. There was no documentation of what efforts were made to prevent Patient #1 from leaving.

4. In a phone interview on 1/22/2021 at 8:32 AM, Patient #1 stated he became upset because he could not get anyone to help him to the bathroom or get any food. Patient #1 stated he asked multiple staff members for something to eat. Patient #1 stated each staff member would tell him they would get him something to eat, but no one ever brought him any food. Patient #1 stated if he was not supposed to eat because of the tests, no one ever told him. Patient #1 stated he got upset at the doctor [Physician #1], because the doctor was sitting behind the desk and would not help him or get someone to help him. Patient #1 stated when his significant other asked Physician #1 why he was sitting behind the desk and not helping Patient #1, his significant other told him Physician #1 told her that he wanted to see what Patient #1 would do. Patient #1 stated he became very angry at the doctor and the nurses and felt like he was being mistreated. Patient #1 stated he decided to leave the hospital against medical advice.

In a phone interview on 1/22/2021 at 9:14 AM, Nurse #2 stated Patient #1 became very irate, and she attempted to talk to him. Nurse #2 stated Patient #1 and Physician #1 got into an argument, and Physician #1 told Patient #1 he could not be verbally abusive toward nursing staff. Nurse #2 stated she and Nurse #3 went into the room to talk to Patient #1 and try to calm him down.

In a phone interview on 1/22/2021 at 11:12 AM, Nurse #1 stated when a patient wanted to leave AMA, the nurse was supposed to try to talk them out of it and call the doctor. When asked about what the nurse should document in the medical record when a patient left AMA, Nurse #1 stated, "I don't know if you're supposed to document anything, sometimes you put in a note and sometimes you don't. You document you notified the doctor and that the patient left AMA."

Based on policy review, medical record review, and interview, the hospital failed to ensure a practitioner responsible for the care of the patient ordered a diet for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the facility policy "Diet Orders" revealed, "...POLICY: The responsible physician orders the patient diet prior to the service of the diet...Physician...Writes diet order in medical record...Writes a diet order for "NPO [nothing by mouth]" when a patient is not allowed oral intake..."

2. Medical record review for Patient #1 revealed an admission date of 7/4/2020 at 5:31 PM with diagnoses which included Palsy and Acute Kidney Injury.

A physician's order dated 7/5/2020 at 12:46 PM (19 hours 15 minutes after admission) revealed a cardiac diet order. There was no physician's order for a diet prior to this order.

The Activities of Daily Living flowsheet dated 7/4/2020-7/5/2020 revealed there was no food intake documented for Patient #1 during his hospital stay.

3. In a phone interview on 1/22/2021 at 8:32 AM, Patient #1 stated he asked multiple staff members for something to eat. Patient #1 stated each staff member would tell him they would get him something to eat, but no one ever brought him any food. Patient #1 stated if he was not supposed to eat because of the tests, no one ever told him.

In a phone interview on 1/22/2021 at 10:30 AM, Physician #1 stated Patient #1 was supposed to be NPO until they ruled out a stroke. Physician #1 stated there should have been an order for NPO in the computer.

In an interview in the conference room on 1/22/2021 at 10:44 AM, the Quality Coordinator confirmed there was no physician's order for NPO and no diet order prior to Physician #1's order for a cardiac diet on 7/5/2020 at 12:46 PM.