HospitalInspections.org

Based on record review, policy review, and interviews the hospital failed to assess the ability of 2 patients (Patient #1 and #2) of 7 patients surveyed of their mental capability of making an informed decision ensuring both patients were informed of the risks of leaving the hospital against medical advice while being treated for alcohol withdrawal syndrome (AWS). Failure to ensure the patients could make an informed decision placed the patients with a potential of self-harm.

The findings include:

Patient #1 is a 65-year-old male who was seen in the hospital emergency room on 6/14/20 at approximately 9:00 a.m. requesting to detox from long term use of alcohol. Patient #1 reported to the ER physician he drank 1 and ½ bottles of vodka daily and had been drinking since graduating college.

The hospital has a voluntary behavioral unit to treat psychological issues. Due to Patient #1's blood alcohol being 373 mg/dL (milligrams per deciliter) Patient #1 was admitted to the medical floor to be monitored and treated for AWS. The physician ordered both routine and as needed Ativan to treat the symptoms of AWS.

Patient #1 was assessed using a CIWA assessment tool every two hours by nursing staff from the time he arrived on the medical floor at approximately 3 p.m. on 6/14/20 until 4:00 p.m. on 6/15/2020. Patient #1 was administered Ativan 1 mg by nursing staff due to the signs and symptoms reported by patient #1 and observed by nursing staff when assessing Patient's #1's CIWA score on 6/14/20 at 6:17 p.m. and at 8:33 p.m. Patient #1 was administered Ativan 1 mg due to AWS on 6/15/20 at 12:20 a.m., 6:01 a.m., 8:06 a.m., 10:07 a.m., and 2:34 p.m. Signs and symptoms reported by Patient #1 and observed by the hospital staff during the CIWA assessments were documented as headache, nausea, tactile disturbances, tremor, paroxysmal sweats, visual disturbances, and anxiety.

On 6/15/20 at 3:33 p.m. a psychological assessment was completed on Patient #1 by and Advanced Registered Nurse Practitioner (ARNP) for "Alcohol Detox". The ARNP document Patient #1's mental status as, "Insight is poor. Judgement is poor. Patient is becoming delirious. Is experiencing visual hallucinations form of bugs in so forth on the ceiling of room. He is a little preoccupied. Orientation is likely waxing and waning though he is oriented at this time ...Sleep is interrupted by hallucinations." The ARNP diagnosis Patient #1 with Alcohol Dependence, Alcohol Withdrawal, and Alcohol Withdrawal Delirium (AWD).

Confusion Assessment Method (CAM)
The presence of delirium requires features 1 and 2 and either 3 or 4:
Acute change in mental status with a fluctuating course (feature 1)
Inattention (feature 2)
Disorganized thinking (feature 3)
Altered level of consciousness (feature 4)"

On 6/15/20 at 4:52 p.m., the medical record shows Patient #1 was administered an antipsychotic medication Haldol 2 mg and a Benzodiazepine antianxiety medication Librium 50 mg to treat AWS and AWD symptoms.
There is no documentation of further CIWA assessments or any other nursing assessments completed on Patient #1 after 4:00 p.m. on 6/15/20.

On 6/15/20 at 8:20 p.m., Registered Nurse (RN), Staff A documented, "pt [patient] was sleeping when I walked in to do my nursing assessment and V/S [vital signs] awake pt, he pleasantly says "I can't stay here anymore. I will be back tomorrow", PT also stated he was not ready for detox. AMA [against medical advice] form given and signed by pt."

A form titled, "Release From Responsibility For Discharge" shows the signatures of Patient #1, Staff A, and RN Charge Nurse, Staff B. The form shows Patient #1's signature was obtained on 6/15/20 at 8:06 p.m. The form signed reads, I have been informed of the risk(s) involved and hereby release the attending physician and the facility administration from for any ill effects, which result from such a discharge. The bottom of the form reads, "If the patient lacks physical or mental capacity, the form should be signed by the Surrogate, Proxy, or nearest family member.

There is no documentation in the medical record Patient #1 was assessed to be alert and oriented prior to the resident signing the form. There is no documentation in medical record Patient #1 was informed of the risks of leaving the hospital while actively being treated for AWS and AWD. There is no documentation of any interventions to prevent Patient #1 from leaving against medical advice. There is no documentation in Patient #1's medical record that his attending physician was notified either before or after the patient left the hospital. There is no documentation of any interventions for safely discharging the patient to his home.

A hospital policy titled, "Patient Leaving Against Medical Advice" effective 11/11/16 reads, "Patients with capacity have the right to leave ...against medical advice ...If possible, the physician should attempt to obtain the signed release. In the physician's absence, the responsible staff member should proceed with obtaining the release and the physician should be notified as soon as possible."

A police dispatch record dated 6/15/20 at 9:00 p.m. shows a city police officer called a cab for resident #1 in front of an automobile Dealership which is 7/10 of a mile from the hospital.

On 6/16/20 at 1:52 a.m., Emergency Medical Services (EMS) was dispatched to an address which is 3.8 miles from the hospital according to MapQuest. EMS documented, "pt. found standing alongside ...[a road]. in the company of [Sheriff's Office] personnel on scene ...Pt. States "I want to Detox." Pt. states that he was at [a different hospital at a different location] earlier today for detox, but left approx. 3pm because he did not like the way that he was being treated. Pt. states he was attempting to walk home, but that he got lost. Pt. states he has not had any alcohol today. Pt. states that he has tripped on the sidewalk a few times ..."

An ER record shows Patient #1 was readmitted to the hospital on 6/16/20 at 2:17 a.m. requesting alcohol detox. He was diagnosed with Non-ST elevated myocardial infarction and dehydration.

Review of MapQuest shows Patient #1 lived 8.6 miles from the hospital and when he was found, he was 4.9 miles from his home. In 5 hours after leaving the hospital, Patent #1 had walked 3.7 miles in the direction of his home.

On 7/3/20 at 3:15 p.m., Patient #1 said he was intoxicated when he left the hospital. Patient #1 denied hallucinating prior to leaving the hospital. He said he had two roommates in his room. One of them was passing gas in the bed and another roommate in front of him was having a bowel movement. He said both of his roommates were laughing with each other over their actions. He said a staff nurse came in and asked him where he was going. He said I can't stay here in these circumstances. He said the nurse said he should not leave and another nurse who was in charge came by his door and asked what was going on. The nurse in charge told the other nurse he can leave if he wants to. The staff nurse told him at that time she did not recommend him leaving but he could leave. When asked if he explained to staff what he was seeing and hearing that had upset him, he said, "I thought it was obvious from the smell." He said he did not remember signing a form that he was leaving against medical advice. He said if he did sign the form, he was not cognizant when he signed it. He said he was intoxicated when he left the hospital. When it was explained to him that he had left hospital more than 24 hours after he had last drunk alcohol, he said he thought he had left the hospital the same day he was admitted. He said he left the hospital and was attempting to get home, but he was stumbling around and fell several times. He said at one time he fell into a ditch and was covered head to toe with water. He said he had seen two police officers. One of them called him a cab. He said the cab never came so he continued to walk home. He said the other police officer called the paramedics and they were very nice to him and got him back to the hospital for treatment. He said he was not capable of determining the risk of leaving the hospital when he left. He said he wished one of the staff members would have called security and stopped him from leaving.

Review of hospital records shows Patient #1 did have one roommate while he was at the hospital who was admitted to his room on 6/15/20.

Review of the nursing standard, "Essentials of Nursing Law and Ethics" Chapter 25, page 138-139 "Discharge Against Medical Advice" Author Katherine Demoski

"While it is the physician's responsibility to explain the risks, benefits, and alternatives to patients to enable them to make an informed decision or give informed consent, the nurse may be the key player in getting patients to consider the alternatives or consequences of accepting or refusing care ...

The nurse has a duty to take appropriate action when there is a question of patient competency. The question should be raised with the examining physician and a psychiatric evaluation should be performed, if necessary, prior to allowing the patient to leave. The nurse as well as the provider could be held liable if a patient is allowed to leave against medical advice and there was any question as to the patient's ability to make a decision in his or her best interest."

On 7/1/20 at 2:00 p.m. Staff A said she did no assessments on patient #1 prior to him leaving. Staff A verified she had not documented in the medical record Patient #1 was alert and oriented. She said she had asked him a few questions and thought he was alert and oriented at the time he left. Staff A said she was not aware how he had arrived at the hospital or how he was getting home. She said she though Patient #1 told her he lived across the street. Staff A said she did not contact Patient #1's physician before or after the patient left the building. She said her charge nurse told her she was going to contact the physician.

On 7/2/20 at 9:20 a.m. The Charge Nurse (Staff B) said the wife informed her after the patient left the hospital, he was having problems with his roommate. The Charge Nurse said Patient #1 never said he was having problems with his roommate prior to leaving. The Charge Nurse said it had not been reported to her Patient #1 had been treated for hallucinating earlier in the day on 6/15/20. The Charge Nurse said she never spoke with the attending physician. She said she paged the ARNP who was on call for the attending and ARNP never called her back until after the patient had returned to the emergency room. She said she briefly spoke with the patient but did not assess if he (Patient #1) was alert and oriented. She said the attending nurse told her he was alert.

On 7/2/20 at 2:00 p.m. The ARNP attending Patient #1 on 6/15/20 said she was shocked when the emergency room physician called her when Patient #1 returned to the ER the early morning of 6/16/20. She said she had to assume Patient #1 left the hospital prior to her coming on shift at 6:00 p.m. on 6/15/20. She said no one had notified her the patient had left the building. She said she would have assumed the staff would have called her before the patient left the building to determine the patient's safety prior to him leaving. The ARNP said she did not receive a text from Staff A. The ARNP said Patient #1 was diagnosed with a heart attack related to the stress of AWS when he returned to the ER on 6/16/20. The ARNP was asked if the stress of attempting to walk home could have contributed to the heart attack. She said she was not sure how far Patient #1 had walked.


2. A review of the record for Patient #2 with the Associate Chief Nursing Officer (ACNO), finds documented the patient was admitted to the Emergency Department (ED) on 6/23/20 at 7:09 p.m. requesting detoxification from excessive alcohol consumption. The patient was admitted to an inpatient bed on 5 South, a med/surg unit, on 6/24/20 at 12:36 a.m. The patient presented with a blood alcohol of 310 mg/dL (milligrams per deciliter), a blood pressure of 152/91, and heart rate of 150 beats per minute. The ACNO said this is a blood alcohol level too high to be admitted to the psych nursing unit, so the patient is admitted to a medical floor and treated on a CIWA (Clinical Institute Withdrawal Assessment) protocol - used when a care provider knows that an individual is going through the process of alcohol detoxification for making clinical assessments regarding alcohol withdrawal symptoms and management on a medical unit. The CIWA assessment produces a numeric score for ten symptoms. A score of (0) zero means no symptoms. Patient #2 had an initial score of 6 upon arrival to the medical unit 5 South.

The record documents that on 6/24/20 at 9:55 p.m., Patient #2 signed himself out of the hospital. The record documents Patient #2 was put on the list for discharge planning on 6/24/20 at 7:19 a.m., based on active substance abuse. On 6/24/20 at 3:56 p.m., the discharge planner attempted an interview with the patient and recorded: "patient presented as lethargic and not easily arousable, will re-attempt tomorrow".
The last CIWA assessment performed on 6/24/20 at 8:00 p.m. produced a score of 8. The patient's blood pressure on 6/24/20 at 8:55 p.m. was 167/107. There were no nursing progress notes produced for this discharge. There is no documentation of the patient being informed of the risk to the patient of leaving with symptoms of detoxification and very high blood pressure. There is no documentation of physician recommendations. There is no documented assessment of the patient at the time of the discharge. The AMA form is witnessed by only one nurse when two witnesses needed.

In an interview on 7/1/20 at 11:10 a.m., the Nursing Director of the Psychiatric Unit said admission to the unit is voluntary, however, sometimes the patient decides; "I don't want to be here." The director said if a desire to leave against medical advice (AMA) is expressed the nurse calls the practitioner. Patient is not allowed to leave before speaking to a medical practitioner and the risks explained. The practitioner may decide a 72 hour hold is necessary and may Marchman Act [The name for a Florida Statute created to help individuals who: (1) have lost the power of self-control over their substance abuse; (2) do not appreciate their own need for help and cannot make rational decisions regarding their care as a result of their substance abuse; (3) have become a danger to themselves or others] or Baker Act the patient if in danger of harm to self. The director said the psych unit has an AMA form. An evaluation with the determination that it is safe for the patient to leave is required. She said the practitioner is available 24/7 to consult with the patient. In order to leave the psych unit AMA the patient must formulate a letter stating thoughts, feelings and impression of stay in the unit.

The director said there are a lot of studies in the literature about AMA discharges. She said the studies report people with substance abuse have higher risk of adverse outcomes.

In an interview on 7/3/20 at 3:40 p.m., the medical practitioner said she was not aware of the patient #2's departure from the hospital. The practitioner said she was not informed before the patient left the facility and does not remember being informed at all. The practitioner reviewed the patient record and said she would have advised against the patient leaving due to the high blood pressure. The practitioner said the preferred scenario is for the practitioner to meet with the patient before they leave the facility AMA. The practitioner said the patient must be evaluated for ability to make an informed decision and a health assessment completed.

In an interview on 7/6/20 at 11:00 a.m., the hospital's Director of Regulatory Compliance and the hospital's Patient Safety Officer both confirmed there is no documentation of explanation of risk to the patient and no health assessment prior to the patient's departure from the facility against medical advice. The administrators acknowledged the risk to the patient and the lack of adequate intervention by hospital staff.