HospitalInspections.org

Based on medical record review, staff interview and review of policy and procedure it was determined the facility failed to ensure the discharge planning process was reassessed on an on-going basis. The facility failed to ensure policy and procedure for patients leaving against medical advice was followed for one (#3) of thirteen patients sampled.

Findings include:

Patient #3 was admitted on 6/26/2015 with a diagnosis of intractable pain and kidney stones. Review of the admitting orders revealed an order for a urologist consultation. On 6/27/2015 documentation revealed a urologist consultation was completed. The consultation revealed the patient complained of pain on movement with some shortness of breath. The urologist documented review of the CT scan revealed a 5 mm (millimeter) non-obstructing kidney stone. The physician documented the patient denied urinary frequency, urgency, dysuria or nausea/vomiting. He noted consideration for other causes of the patient's flank pain should be considered. The urologist recommended follow-up on an outpatient basis with no intervention necessary at that time.

Review of nursing documentation revealed a note dated 6/27/2015 at 12:16 p.m. that stated the patient was seen by the urologist who stated there was no obstruction from the renal stone therefore no interventions were needed at that time. The patient requested to leave AMA (Against Medical Advice). Nursing documentation revealed the risks of leaving were explained to the patient but the patient refused to stay.

Review of the facility policy "Patient Refusal of Further Medical Treatment and Leaving Against Medical Advice" last reviewed 10/2014 stated (1)(a) the attending physician will be informed of the patient's intent to leave.

Review of the record revealed no evidence the attending physician was informed of the patient's request to leave AMA. Review of the attending physician's discharge summary indicated the urologist recommended follow-up on an outpatient basis, the patient was stable for discharge on 6/27/2015 and the patient would follow up as an outpatient with the urologist. Review of the physician's orders revealed no order for discharge.

Interview with the director of patient safety/risk manager on 8/4/2015 at approximately 3:45 p.m. confirmed the findings.