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Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of treatment were explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 20 (Patient #16) sampled patients.

The findings included:

Patient #16 presented to the ED on 3/22/2025 at 3:40 AM, with complaints of back pain. The Medical Screening Examination (MSE) was initiated at 3:43 AM by a Nurse Practitioner (NP). Triage was initiated by an Registered Nurse (RN) at 3:45 AM. The NP who conducted the MSE ordered a Computed Tomography (CT scan - uses x-rays to create cross-sectional images of the inside of the body) of the lumbar spine at 3:46 AM with the results available at 5:45 AM. At 6:55 AM, the nurse documented, "Pt [patient] escorted to the hallway [ED Hallway bed] but refused to be in the hallway and would rather go home. I explained that since he wanted to be seen by a doctor, I need to put him there as there are no available rooms. Patient refused still and left without signing the AMA form."

There was no documentation Patient #16 was informed of the risks and benefits by a medial provider or a completed AMA form in the medical record.

Cross Refer to 2407.

Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of treatment were explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 20 (Patient #16) sampled patients.

The findings included:

1. Review of the policy "Screening Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services- EMTALA [Emergency Medical Treatment and Labor Act] revised 8/29/2024, revealed, "...Policy: It is the policy of each [named hospital] to comply with the...EMTALA... Patients Leaving Hospital against Medical Advice [AMA], Left Without Being Seen [LWBS], or Without Informed Refusal (Elopement) If an individual attempts to leave the Hospital AMA, LWBS, or elopes, personnel should reasonably attempt to obtain the individual's signature on the appropriate form and should attempt to inform the individual of the risk of not waiting to be examined by a provider. Hospital personnel should appropriately document in the medial record or on the Patient Refusal of Medical Treatment And/Or Leaving Hospital Against Medical Advice that the patient was advised of the risks but left AMA/LWBS or had eloped without informed refusal of treatment..."

2. Medical record review for Patient #16 revealed an elderly male who presented to the ED on 3/22/2025 at 3:40 AM, with complaints of chronic back pain that was worse on the day of the ED visit. The Medical Screening Examination (MSE) was initiated at 3:43 AM by Nurse Practitioner (NP #1). Triage was initiated by a RN at 3:45 AM with the following vital signs: BP- 120/86, Temperature- 97.5, Heart Rate- 77, Respirations- 18, Oxygen- 94%. Patient #16 was assigned an ESI acuity level 4. The NP who conducted the MSE and ordered a Computed Tomography scan (CT- a painless medical imaging test that uses x-rays to create cross-sectional images of the inside of the body) of the lumbar spine at 3:46 AM. The CT of the lumbar spine result were documented at 5:45 AM with no acute osseous abnormalities (no recent or serious issues detected in the bones) Chronic anterior vertebral body height loss (the progressive thinning and collapse of the front part of the spine's vertebrae, often caused by repeated or severe osteoporosis-related compression fractures or trauma) and relatively stable grade 1 anterolisthesis (a condition where one vertebra (bone in the spine) slips forward over the vertebra below it) at Lumbar 5 (the lumbar region of the back is the lower back, made up of five vertebrae that are the largest in the body) - Sacrum 1 (the sacrum is a large, triangular shield-shaped bone at the base of the spine, formed by the fusion of five vertebrae; connects to the lumbar spine (S1) secondary to bilateral degenerative facet (a condition affecting both sides of the spine where the cartilage in the facet joints wears away, causing pain, stiffness and potential bone spurs).

At 6:55 AM, RN #2 documented, "Pt [patient] escorted to the hallway [ED Hallway bed] but refused to be in the hallway and would rather go home. I explained that since he wanted to be seen by a doctor, I need to put him there as there are no available rooms. Patient refused still and left without signing the AMA form."

There was no documentation the nurse notified the Nurse Practitioner or a physician so they could discuss the risks of leaving the ED without a full medical examination to determine if his chief complaint at the time he presented to the ED was an emergency medical condition. There was no documented AMA form in the medical record with the patient refusal to sign.

During an interview on 8/19/2025 at 3:00 PM, the ED Nursing Manager verified there should be an AMA form in the medical record, even if the patient refused to sign. He stated the expectation was for staff to complete the AMA form, attempt to get the patient to sign the form and if the patient refused, the staff would document the refusal on the form. The ED Nursing Manager stated any staff member that learns a patient is attempting to leave should notify the provider (NP/Physician) so the provider can fully explain the risks of leaving the ED.