HospitalInspections.org

Based on staff interview, medical record and policy review, the Critical Access Hospital (CAH) staff failed to follow their policy related to a patient leaving the hospital Against Medical Advice (AMA) when they allowed 1 of 1 patients selected (Patient #1) who presented to the Emergency Department (ED) to leave the ED AMA, and then did not notify Patient #1's friends or caregivers of Patient #1's departure. Failure to follow the CAH's AMA policy resulted in Patient #1 leaving the hospital on foot and being unsupervised in the community for almost 2 hours before Patient #1 was located by Sheriff's deputies and returned to the CAH ED. The CAH identified an average of 718 ED visits per month.

Findings include:

1. Review of the policy "Managing the Patient Who Wants to Leave the Hospital Against Medical Advice (AMA)", last reviewed 12/2020, revealed in part: "A competent, conscious adult ... authorized to consent to care under state law has a right to leave the hospital without a physician order even though it may be detrimental to the health of the patient."

The policy made an exception to the language above when a patient is a " ... Threat to public health and safety ...", and the policy required that the staff "Make patient's family aware of patient's desire to leave -- and continued need for hospital care", and document the names of "... relatives or others notified of the patient's decision to leave."


2. Review of Patient #1's Clinic medical record revealed the following in part:

On 8/18/21, Patient #1's friends (a husband and wife) sent Clinic Physician A a copy of a letter they sent to a physician at Hospital A (where Patient #1 was seen for memory care) outlining their concerns regarding Patient #1. The letter included copies of emails from Patient #1's primary home health caregivers that detailed their concerns regarding Patient #1 including: Patient #1 seeing ladies in their home, Patient #1 moving objects and then blaming it on the ladies in the home, and Patient #1 talking about imaginary people and a dog who are outside their home. Patient #1 believed they were being held a prisoner, said they had a loaded gun and the safety was off, and if home health staff ever tried to take Patient #1 away, Patient #1 would shoot the home health care staff.

The letter also noted that the husband and wife were close friends of Patient #1 since they moved to the area in 1976. Patient #1 relied on them for assistance and counsel on various issues. They noted Patient #1's inability to remember things and increasing need of assistance, Patient #1's daily hallucinations, and concern that Patient #1 lived in a rural setting and could wander off without anyone noticing.

Patient #1's friend (the husband in the couple writing the letter) had financial Power of Attorney but not medical Power of Attorney for Patient #1. Patient #1 did not want to leave their home, but the friends were concerned that Patient #1 was unable to remain on their own. Patient #1's friends requested the clinic staff call them for any questions and included their home phone number and 2 cell phone numbers as contact information.

On 8/19/21 at 12:11 PM, Clinic Physician A documented Patient #1 was an 83 year-old accompanied to the clinic by a friend (the wife in the couple writing the letter). Patient #1 had dementia and was seen in Hospital A's Memory Clinic. Patient #1 had visual hallucinations and delusions of people and a dog in their home. Patient #1 had paranoia and had made threats to shoot people who would come to their home. Patient #1 had several guns at home, 2 were unloaded, but 1 was unable to be found. Home health agency staff had declined to care for Patient #1 due to those threats. Clinic Physician A documented that Patient #1's friend had noticed increased agitation, and was worried for Patient #1's and other people's safety. Patient #1 had no family.

A mini mental exam (used to test multiple mental abilities, including learning, thinking, reasoning, remembering, problem solving, decision making, and attention) showed moderate dementia. Patient #1 also had diabetes.

Clinic Physician A and RN B signed a Marion County legal document that alleged that Patient #1 was seriously mentally impaired. RN B noted that they had assessed the patient and read the materials provided by Patient #1's friends.


3. Review of Patient #1's ED medical record revealed the following in part:

On 8/19/21 at 12:18 PM, ED Physician C saw Patient #1 in the ED, noted Patent #1 was seen in the clinic earlier that day because Patient #1's friends had concerns about Patient #1's threats made to home health staff and friends, Patient #1's increase in hallucinations, and Patient #1's decreased ability to care for themselves in the home where Patient #1 lived alone. Patient #1 had threatened to shoot anyone who came to the house, and had guns of unknown whereabouts. Patient #1 was unaccompanied in the CAH's ED, but ED Physician C was able to contact Patient #1's friend who confirmed these concerns, and was concerned Patient #1 may hurt someone with these guns. Patient #1's Friend was concerned that Patient #1 would get themselves into trouble, as Patient #1 was wandering around the neighborhood more often.

Patient #1 was confused about why they were in the ED and did not feel they needed to be seen. Patient #1 left the ED. The CAH staff did not have power to stop Patient #1 from leaving because the court committal paperwork (a legal document allowing the hospital staff to detain Patient #1 at the CAH against Patient #1's will) had not been approved yet. The ED staff called the courthouse, expedited the magistrate signing the court committal paperwork for Patient #1, contacted law enforcement to return Patient #1 to the hospital under the court committal order, the law enforcement officers found Patient #1 at Patient #1's home, and the law enforcement officers returned Patient #1 to the ED.


ED RN D documented:

- 1:37 PM, Patient #1 walked out of the ED room and told ED RN D that Patient #1 was leaving the CAH, since Patient #1 was a guest at the CAH, and Patient #1 wanted to talk to the CAH's administration. Patient #1 proceeded to walk out of the building, Patient #1 tried to orient themselves to their location by asking, "Are we in Pella?" "What street is this?" ED Physician C came out to talk to Patient #1.

- 1:59 PM, Patient #1 left the hospital. ED RN D noted ED Physician C indicated they had not received the court committal order yet and instructed ED RN D to call the Clerk of the Court to determine the status of Patient #1's court committal order.

- 2:00 PM, The Clerk of Court indicated they would notify the judge that Patient #1 had left the hospital Against Medical Advice.

- 2:12 PM, ED RN D contacted the Sheriff's office and the sheriff's deputies will find Patient #1 and return Patient #1 to the hospital.

- 3:28 PM, Sheriff's deputies arrived with Patient #1.

- 3:39 PM, ED Physician C called Patient #1's friend (after Patient #1 was gone from the ED for almost 2 hours).

- 7:45 PM, The ED staff transferred Patient #1 to an inpatient behavioral health unit.

ED documentation does not address any consideration of the AMA policy exception based on public health and safety, nor was there any documentation that Patient #1's friends (emergency contacts) were notified when Patient #1 left AMA.


4. During an interview on 9/13/21 at 3:30 PM, Clinic Physician A saw Patient #1 several times in the clinic for memory loss and dementia before the visit on 8/19/21. Clinic Physician A recalled they received a message the day before from a caregiver/friend who had concerns about Patient #1's safety and the safety of others because there reportedly were some guns in Patient #1's home. Patient #1 had been receiving assistance from home health providers and the home health providers had declined to see Patient #1 because of the safety concerns.

Patient #1 was previously seen by Hospital A's Memory Clinic because Patient #1 had difficulties with memory and hallucinations, obtaining meals, and caring for themselves. Patient #1 had previously declined placement in a care facility, but now Clinic Physician A was worried for Patient #1's safety, as well as the people around Patient #1, given the significant concerns with Patient #1's access to firearms. Clinic Physician A wanted Patient #1 to have an urgent evaluation in the ED, so they called the courthouse for guidance on the proper forms/process for a court committal order, completed the forms, and submitted them to the court house. The Medical Clinic Supervisor walked Patient #1 and Patient #1's friend over to to the ED. The Medical Clinic Supervisor spoke with the ED staff directly, so they were aware of the situation.


5. During an interview on 9/13/21 at 3:10 PM, Clinic RN B revealed Patient #1 had dementia, only knew their name (not their location nor a general sense of time). Patient #1 was nice but definitely a harm to themselves and possibly others. Patient #1 threatened to punch Clinic RN B when they tried to draw blood from Patient #1. Clinic RN B remembered Patient #1's friends had written a letter to the clinic telling them that Patient #1 had a gun, Patient #1 had some threatening behaviors, and Patient #1 was paranoid that people were in their home. Clinic RN B had not met Patient #1 prior to 8/19/21, but was obvious Patient #1 was not "with it". Clinic RN B recalled that Patient #1 walked to the ED accompanied by their friend and the Medical Clinic Supervisor.

6. During an interview on 9/14/21 at 8:00 AM, the Medical Clinic Supervisor indicated they assisted with the legal aspects and paperwork for the court committal order for Patient #1. Clinic Physician A did not think Patient #1 was mentally stable and Patient #1 should not leave the hospital to go home. The Medical Clinic Supervisor visited with Patient #1, who had no idea where they were or why they were there. Patient #1 indicated their favorite place to travel was the North Pole. The Medical Clinic Supervisor had worked with a lot of demented patients and Patient #1 was not in their right mind, nor was Patient #1 mentally competent. It was a hot day and Patient #1 had on long pants, long sleeves, a sweater and a shawl.

The Medical Clinic Supervisor told the ED staff that they had filled out court committal paperwork for Patient #1 and Patient #1 just needed someplace safe until the ED staff received the court committal order from the judge. The Medical Clinic Supervisor escorted Patient #1 and their friend to the ED. The Medical Clinic Supervisor was not sure why Patient #1's friend left, but remembered Patient #1's friend assuring Patient #1 that Patient #1 was in good hands, and that the ED staff would take good care of Patient #1. The Medical Clinic Supervisor told Patient #1's friend to call the ED if they had any questions, and assured Patient #1's friend that the ED staff would call Patient #1's friend once the ED staff had more information.


7. During an interview on 9/8/21 at 3:30 PM, ED RN E recalled that Patient #1 was brought to the clinic by a friend earlier that day, and the clinic conveyed to the ED staff that Patient #1 was unable to take care of themselves at home and Patient #1 was aggressive toward home health staff. ED RN E did the triage for Patient #1 and handed off Patient #1's care to ED RN D. ED RN E was not aware that Patient #1 had left AMA. If a patient is confused and can't make their own decisions, usually the ED staff will request someone who can make decisions for the patient stays with the patient.

8. During an interview on 9/9/21 at 8:00 AM, ED Physician C recalled hearing the clinic staff had initiated a court committal order for an evaluation of Patient #1. It was confusing at first because someone, somewhere told Patient #1's friend that they should not accompany Patient #1 to the ED. At least initially, Patient #1 did not know why they were in the ED. Patient #1 thought they had gone with their friend for the friend's appointment appointment and now Patient #1 was the patient. Patient #1 was sure they shouldn't be in the ED. So right off the bat, ED Physician C knew something was going on because Patient #1's story did not match the information ED Physician C received from the clinic. Patient #1's main concern was hallucinations and seeing people in their home. ED Physician C did not know how long Patient #1 was in the ED, but Patient #1 suddenly decided they wanted to leave. The ED staff attempted to talk to Patient #1 and convince them to stay in the ED. ED Physician C went into the CAH's parking lot and talked with Patient #1. ED Physician C told Patient #1 that the CAH staff could not keep Patient #1 at the CAH against their will without a court committal order, but the police would later come looking for Patient #1 and the CAH ED staff would finish their exam at that time.

Since the judge had not issued a court committal order, ED Physician C could not stop Patient #1 from leaving the ED, despite ED Physician C's concerns regarding Patient #1's ability to care for themselves, due to Patient #1's early dementia and paranoid behavior. Patient #1's behavior escalated pretty quickly and ED Physician C asked the ED staff to try to expedite the process of obtaining a court committal order. At an unknown time after Patient #1 left the ED, Patient #1's friends called the ED, inquiring about Patient #1.



9. During an interview on 9/9/21 at 11:00 AM, ED RN D indicated they were walking towards Patient #1's room when Patient #1 charged out of their ED room. Patient #1 was adamant they were a guest in the ED and Patient #1 claimed they had been in the ED for 90 minutes and the ED staff had not done anything for Patient #1. The ED staff could not convince Patient #1 they were a patient and the ED staff had provided care to Patient #1. Patient #1 left the ED room and walked out into the ED lobby. Patient #1 demanded to speak with the CAH's administration. ED Physician C spoke with Patient #1 privately outside in the ED's parking lot.

While Patient #1 was outside, ED RN D contacted the ED Manager to determine if the court had issued a court committal order. The ED Manager confirmed that the judge had not issued a court committal order and informed ED RN D that, without a court committal order, the ED staff could not hold Patient #1 at the CAH against Patient #1's wishes.

As Patient #1 was standing outside the CAH's ED, ED RN D heard Patient #1 attempt to orient themselves to their location by asking, "We are in Pella?" "This is Jefferson Street, right? ED RN D know Patient #1 had dementia, lived alone, was seeing things at home (hallucinations), and Patient #1 may have had access to guns. ED RN D believed Patient #1 had previously made threats of violence towards others.

When Patient #1 left the ED, it was a hot day outside. ED RN D asked Patient #1 if there was anyone ED RN D could contact to let them know Patient #1 was leaving the CAH's ED. Patient #1 declined ED RN D's offer to notify someone that Patient #1 left the ED. ED RN D believed that, since Patient #1 did not want ED RN D to notify anyone about Patient #1 leaving the ED, even though ED RN D had concerns about Patient #1 not calling their friends in the heat.

ED RN D did what they thought was best in the situation and called the Clerk of the Court. ED RN D confirmed that ED Physician C spoke Patient #1's friends when Patient #1 returned to the ED (approximately 2 hours after Patient #1 left the ED.



10. During an interview on 9/13/21 at 3:45 PM, The ED Manager recalled talking to Patient #1 when Patient #1 was trying to leave the ED and Patient #1 said they were a guest in the ED and there was no need to call anyone to let them know Patient #1 was leaving the ED. The ED Manager thought Patient #1 sounded like they were of sound mind and body, but acknowledged that 1 minute Patient #1 was lucid and knew what was going on, and the next minute Patient #1 might not be lucid. The ED Manager also acknowledged that they heard Patient #1 had hallucinations and there were concerns about guns in Patient #1's home.

The ED Manager acknowledged that the CAH's AMA policy required an exception to allowing a patient to leave the hospital AMA if the patient was a threat to public health and safety (including mental health). Patient #1's contacts weren't technically family, and based on the policy, the policy required the ED staff to call family (Patient #1 didn't have any family.) ED Manager opined maybe they would need to change the policy. The ED Manager knew that ED Physician C did talk to the friends and said the ED staff called Patient #1's friends "rather soon". The ED staff informed the ED Manager that the ED staff already had law enforcement officers to pick up Patient #1 when the ED Manager spoke with the ED staff after Patient #1 left the hospital AMA.