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Based on the facility's policy and procedure and the review of records, the facility failed to ensure that 1 out of 20 Sampled Patients (SP)'s medical records contained a description of the examination, treatment, or both if applicable, that was refused by SP#l. Additionally, the facility failed to take all reasonable steps to secure SP#1's written informed refusal on 12/06/2023.

Refer to findings in A-2407

Based on the facility's policy and procedure and the review of records, the facility failed to ensure that 1 out of 20 Sampled Patients (SP)'s medical records contained a description of the examination, treatment, or both if applicable, that was refused by SP#l. Additionally, the facility failed to take all reasonable steps to secure SP#1's written informed refusal on 12/06/2023.

Findings include:

Review of the facility's Policy No. 136 Section: 100-200 Administration entitled Patient Leaving Hospital Against Medical Advice last revised on 10/31/2023 included but wasn't limited to:

I. Purpose:

To describe the responsibility of _____System towards the act of - Leaving Against Medical Advice "AMA" upon a patient's release.

II. Procedure:
A. Any patient leaving a _____facility who has not been discharged by a physician must have a properly executed Patient Leaving Hospital Against Medial Advice/ Refusal of Treatment/Procedure (AMA form) (Form C602c/C602s).
1. It is the physician's responsibility to see that the AMA form is properly executed.
2. This specifically requires that the patient, or the individual who may legally consent for the patient, must be made fully aware of the possible medical risks associated with leaving against medical advice.

Review of Emergency Department (ED) records for Patient #1 on 12/06/2023 documented Patient #1 seen, evaluated and treated appropriately for a left lateral flank stab wound 3 - 4 days old with IV(Intravenous) fluids, IV antibiotics and tetanus vaccine. Patient #1 was advised to stay for overnight observation however requested discharge because of a current house arrest program and needed to return home. Patient #1 was discharged as requested against medical advice on his own free will at 2:12 PM on 12/06/2023. Patient #1 was provided with discharge instructions, patient education, and a prescription for medication.

Review of SP#1's medical record revealed a section entitled "Final report" completed on 12/06/2023 at 13:56 by ED Physician/ Staff G.

Basic information:
History of present illness
The patient presents with Stab wound. Additional history: Patient reports ambulatory to the emergency department with a stab wound to the left flank of the abdomen sustained 4 days ago. Patient presents with normal vital signs. Stab wound site with underlying hematoma. No active bleeding. No other associated injuries. Last tetanus unknown.

12/06/2023 13:54:56 EST trauma saw and evaluated patient who recommended admission to observation overnight however patient requested discharge as he is currently at a house arrest program and needs to return. He will return to ED if any concerning signs or symptoms arise.

Impression and Plan:
Diagnosis
Stab wound of lateral abdomen
Abdominal wall hematoma
Left against medical advice

Plan:
Condition: Unchanged
Disposition: 12/06/2023 13:40:00, left against medical advice
Patient was given the following educational materials: Medicine for Pain, Laceration, Old: Not sutured
Follow up with: Follow up with primary care provider Within 1-2 days. Return to ER as needed: Primary care no physician within 1-2 days.
Counseled: Patient, regarding diagnosis, regarding diagnosis results, regarding treatment plan, regarding prescription, patient indicated understanding of instructions.

Further record review revealed no documentation that the facility executed the Patient Leaving Hospital Against Medial Advice/ Refusal of Treatment/Procedure form or took all reasonable steps to secure SP#1's written informed refusal when the patient was discharged on 12/06/2023.