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ST MARY'S REGIONAL MEDICAL CENTER
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on record review and interview, the hospital failed to ensure adherence to policy for one (Pt #14) of 20 patient records reviewed.
Findings:
Pt #14
Review of policy titled "630-173 Release from Responsibility for Discharge from ED" read in part, "If even after all the explanations, the patient still opts to leave or not be examined, the Release from Responsibility for Discharge form should be brought to the patient and a request made to have the patient sign it. Again, you should elicit friends and family's help to get this signed. If the patient still refuses to sign the form this should be documented with explanation of all attempts to get it signed."
On 06/17/25 at 1:42 am, Pt #14 arrived to the ED with a complaint of medication concerns (had been off of medications and thinks an adjustment needs to be made). Triage began at 1:44 am and the patient was given an emergency severity index (ESI) of 2.
The ED Nursing Note showed at 2:40 am "The patient exited her room and demanded we bring her phone so she could call her attorney to sue the hospital. The patient was yelling at the staff and being aggressive. I informed the patient that she was free to leave if she did not want to have an evaluation by a mental health provider. The patient states that all she wanted was to administer her psychiatric medication. I did tell her that in order for us to treat her we would have to have a medical workup. The patient refused to provide specimens and stated she was going to leave. I returned the patient's belongings to her and provided her with information on URC. The patient stated she would call a taxi and go to the URC. The patient was able to ambulate to the lobby where we will await her."
A review of the ED record showed no evidence the patient was given the "Release from Responsibility for Discharge" form, a request for the patient to sign the form or that the patient refused to sign the form.
On 06/25/25 at 2:43 pm, Staff K stated they did not have Pt #14 sign a "Release from Responsibility for Discharge" form.