HospitalInspections.org

Based on record review and interview, the facility failed to ensure that the medical record contained the appropriate documentation per the facility's policy for 2 of 3 patients ( #8 and #15) who left the Emergency Department AMA (Against Medical Advice) in a total sample of 20 medical records reviewed.

Findings include:

Review of the facility policy titled, "Leaving Against Medical Advice (AMA) (System)" #11387877 dated 03/2022 revealed, under "Policy: ... IV for capacitated adults and legal representatives that make a decision to leave AMA despite all attempts to persuade the patient otherwise, Aspirus employees will attempt to 1. Obtain the signature of the capacitated patient or legal representative that has decided to leave AMA or refusal to sign and include the appropriate form in the medical record..."

Medical record review of Pt. (patient) #15 revealed a 58 year old with an admission to the ED (Emergency Department) on 11/22/2022 at 11:50 AM seeking treatment for symptoms of alcohol withdrawal and chest pain. Blood work and a heart tracing were completed and results revealed elevated cardiac enzymes (indicators for heart damage). Review of the "ED Provider Note" dated 11/22/2022 at 4:32 PM revealed, "...agree (with Hospitalist) that patient should be admitted for possible ACS (acute coronary syndrome). Patient was informed he may be developing a heart attack and is a very high risk...Despite this, patient states that he wants to go home. Patient will therefore sign out against medical advice."

There was no documentation that the patient was presented with the AMA form to sign. There was no AMA form in the patient's medical record.

On 2/7/2023 at 9:10 AM in an interview with Quality Director A, Director A stated, "Staff should have completed the AMA form indicating that he left without signing it. There is no form in the medical record so obviously that didn't happen."


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A review of Patient #8's medical record revealed a 29 year old with an admission to the ED (Emergency Department) on 10/17/2022 at 7:30 AM with a chief complaint of "psychiatric problem". A medical screening exam was performed and triage completed with an acuity level of 2 assigned. A suicide risk score was documented as "High Risk". A review of ED Provider Note dated 10/17/2022 at 8:06 AM revealed, "...My concern is this patient is a danger to himself and others. He/she did make threats to ED staff. Reported county delegate was contacted and he/she came to evaluate patient and agrees with chapter however, law enforcement states patient denies suicidal or homicidal ideations and therefore patient well (sic) not be captured (sic). Family is going to proceed with a 3 party petition to try to get the patient involuntarily committed. Patient did leave AMA (against medical advice) and unfortunately, I have no grounds to hold the patient against his/her will."

There was no documentation that the patient was presented with the AMA form to sign. There was no AMA form in the patient's medical record.

An interview was conducted with Quality Director A on 2/7/2023 at 9:10 AM and agreed the AMA form should have been completed by staff when they realized the patient eloped without signing the form.

Based on medical record review and interview the facility failed to provide a safe discharge from the Emergency Department for 1 of 2 patients (#20) with suicidal ideation who left AMA (Against Medical Advice) from the ED (Emergency Department) in a total of 20 records reviewed.

Findings include:

Review of the facility policy titled, "Suicide/Self Harm Precautions" #11582272 dated 04/2022 revealed, "Policy:...If a patient agrees to voluntary admission to a Behavioral Health setting and then later wants to leave prior to transfer, Law Enforcement is notified for assistance. If a patient attempts to leave before an Involuntary Detention Order is received and is determined to be a threat to self or others, Law Enforcement may be called...ED Procedure: A. During triage, note in the EHR (electronic medical record) that the patient is being evaluated for behavioral or mental health issues. This will trigger the Columbia Suicide Scale (a questionnaire used to assess suicide risk) or RSQ-4 (a risk suicide questionnaire for children) Tool based on age. Any patient assessed as high risk per the tool will be placed on suicide precautions/observation..."

Review of Pt. #20's medical record revealed a 32 year old with an admission to the ED on 10/19/2022 at 8:45 PM for suicidal ideation (preoccupation with the idea of suicide). The ED Triage Note revealed that the patient stated, "I want to end my life. I walked into traffic today. I have a plan but am not going to say what it is." The Columbia Suicide Assessment was performed and the score was resulted as "High Risk". The patient was placed on suicide precautions with a 1:1 sitter in the ED.

Review of the "ED Provider Note" dated 10/19/2022 at 9:39 PM revealed, "...Patient states that over the last 3 weeks he has been having worsening depression with passive suicidal ideations and over the past day he has been feeling more suicidal and has intentionally walked into traffic a couple of times and has reported a plan for suicide..."

Review of the "ED Provider Note Assessment and Plan" dated 10/19/2022 at 10:29 PM revealed, "...Patient was adamant that he have his IPad in MAGU (sic) (BHU - Behavioral Health Unit). This is against policy. Patient was informed of this. He states that he must have his audio books. He was offered a CD player with headphones but he states this is insufficient and therefore left against medical advice."

The record revealed an "Other Clinical Notes" dated 10/19/2022 at 10:43 PM from RN (Registered Nurse) R, "RN informed by physician that the patient has left..."

On 2/7/2023 at 10:20 AM in an interview with RN Q, RN Q stated that she was a nurse in behavioral health for 13 years. When asked about safe discharge for a suicidal patient RN Q stated that if a patient has a plan (for taking their life) and they leave AMA we should be calling law enforcement to find them and bring them back. At that point they would probably be chaptered. (Chapter 51 involuntary hold)".

The attending physician for Pt. #20's ED visit was not available for interview.

On 2/7/2023 at 10:40 AM in an interview with ED Medical Director N, Medical Director N was asked to review the 10/19/2022 ED record for Pt. #20. After review Medical Director N stated, "I see no documentation that law enforcement was called when this patient left AMA and we should have. I will not disagree with the fact that we didn't provide him with a safe discharge."

Based on record review and interview, the facility staff failed to provide stabilizing treatment for mania by ensuring admission to the facility's psychiatric unit for 1 of 1 patient (Patient #1) who presented to the Emergency Department with bipolar disorder and suicidal ideation and requesting admission to the psychiatric unit in a total sample of 20 medical records reviewed. See tag A-2407.

Based on record review and interview, the facility staff failed to provide stabilizing treatment for mania by ensuring admission to the facility's psychiatric unit for 1 of 1 patient (Patient #1) who presented to the Emergency Department with bipolar disorder and suicidal ideation and requesting admission to the psychiatric unit in a total sample of 20 medical records reviewed.

Findings:

A review of Patient #1's medical record reveals Patient #1 arrived in the Emergency Department (ED) on 11/29/2023 at 2:25 PM with a complaint of suicidal ideations. Patient #1 was assigned an acuity level of 2 at the time of triage at 2:27 PM. ED Physician S performed a medical screening exam at 3:15 PM. A Columbia Suicide Severity Rating Scale screening was conducted at 3:43 PM and revealed, "...1. Wish to be dead: Yes; 2. Suicidal Thoughts: Yes; 3. Suicidal Thoughts with Method Without Specific Plan or Intent to Act: Yes; 4. Suicidal Intent Without Specific Plan: No; 5. Suicide Intent with Specific Plan: No; 6. Suicide Behavior Question: Yes; How long ago did you do any of these?: Over a year ago... Suicide Risk Score/Interventions: Low Risk; Low Risk Interventions: Notified Provider of positive screen but low risk.

A review of ED physician S's Assessment and Plan note revealed, "...Diagnosis management comments: Discussed the case with (Psychiatrist P) who refused to admit the patient secondary to the fact that he/she used to work in the unit 2 years ago. (Patient #1) was frustrated about this but stated that it did not really changes (sic) state of mind, he/she did not feel increasingly hopeless or suicidal secondary to this. He/She stated that he/she was not surprised by this outcome given the physician that was on call tonight but that he/she thought the more ethical outcome would of been helping someone who arrived in the hospital regardless of their previous employment. I had an extensive conversation with (Psychiatrist P) expressing the same but, it was still thought that the patient should not be admitted here ...At this point, the patient is likely at low risk for suicide although he/she is chronically more elevated than the average population ..."

An interview was conducted with ED RN U on 2/7/2023 at 11:00 AM. ED RN U stated Psychiatrist P wanted someone to witness the phone conversation between Psychiatrist P and Patient #1 by using a speaker phone and staying with Patient #1 to be able to hear what was said. ED RN U said they asked Psychiatrist P to come to the ED to speak with Patient #1 face to face at least 2 or 3 times but Psychiatrist P never responded to those requests. ED RN U stated they stood in the doorway of the ED room where Patient #1 was speaking to Psychiatrist P over the phone and said that Psychiatrist P told Patient #1 there was a conflict of interest due to Patient #1's past work history in the psychiatric unit. ED RN U stated that Patient #1 told Psychiatrist P that it had been about 2 to 3 years since Patient #1 worked in the unit and that should be enough time away. ED RN U stated that Psychiatrist P told Patient #1 that they had a different type of relationship and that Patient #1 knew the routine and how things worked in the unit. Psychiatrist P said that it wouldn't be in Patient #1's best interest considering that past relationship. Patient #1 disagreed with Psychiatrist P but Psychiatrist P told Patient #1 they should go to another facility farther away. ED RN U stated that ED Physician S and Psychiatrist P then had a "heated phone discussion" regarding the admission of Patient #1 with ED Physician S wanting to have Patient #1 admitted but Psychiatrist P refusing to admit. When ED RN U asked if psychiatrists routinely came to the ED to speak with patients, ED RN U stated, "No. Sometimes they have a nurse come down." When asked if ED RN U ever heard of a patient being refused admission due to a conflict of interest ED RN U stated, "No."

An interview was conducted with Quality Director A on 2/7/2023 at 11:50 AM. Quality Director A explained that the Mental Health Unit had a bed capacity and staffing for 5 patients on 11/29/2022 and the maximum census for that day was only 2. Quality Director A stated, "They could have taken the patient."

Patient #1 was discharged from the ED on 10/19/2022. Patient #1 then presented to the ED at (hospital V) which is approximately 100 miles away on 10/20/2022 and was admitted to (hospital V) psychiatric unit.

The facility does not have a policy that provides criteria for denial of admission to a specialty unit when the unit has the capacity to provide treatment.