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Based on patient, family, and staff interview and review of medical records, staff documentation, emergency medical service (EMS) reports, and policies and procedures, it was determined the hospital failed to comply with the requirements at 489.20. Specifically, the hospital failed to ensure staff followed their policy and procedures for providing information about the risks versus benefits of leaving against medical advice (AMA). This failure affected 1 of 3 sample patients (#15) who departed from the emergency department (ED) AMA. The findings were:

Interview with the administrator, director of administration, and director of acute care on 5/3/17 at 4:30 PM revealed the following information: Patient #15 came to the emergency department (ED) lobby on 4/21/17 and asked to talk with a physician. The patient and spouse departed in their private vehicle after talking with the physician. This encounter was not documented in the medical record because the patient was not admitted. Later the hospital that admitted the patient on 4/21/17 called and reported the patient arrived by EMS. The director of acute care called the Center for Medicare and Medicaid regional office and reported the incident as a possible EMTALA violation. The message she received from the regional office was they had done the correct thing in reporting the incident; and there would be no further investigation. The physician and nurse who saw the patient in the ED lobby on 4/21/17 were instructed to document the event. For most cases like this, staff had the patient sign an AMA form, but this was not done for patient #15.

Review of RN #1's documentation, dated 4/26/17, revealed the following information: On 4/21/17, patient #15 presented to the ED lobby and stated s/he did not want the doctors to touch him/her. The patient asked if s/he could transport him/herself to [hospital name] or if arrangements needed to be made to transport by EMS due to his/her dehisced abdominal wound. The patient had an occlusive dressing covering the abdominal wound. The dressing was moist, and the patient denied acute distress. The patient talked with the physician and the physician's medical student about s/he and spouse driving to [hospital name] for care of his/her dehisced abdominal wound. The patient was stable and physician #1 advised the patient to travel in their private vehicle. During an interview on 5/4/17 at 11:05 AM, RN #1 stated she should have instructed the patient to sign an AMA form, but she did not think about this at that time.

Interview on 5/4/17 at 10:50 AM with the physician (physician #1) who saw the patient in the ED lobby on 4/21/17 revealed the following information: The physician talked with the patient in the lobby and observed the patient's wound. The patient wanted to know whether s/he should go to [hospital name] by private vehicle or EMS transport. The wound was covered and protected with a dressing. There was nothing the EMS could do that the patient and spouse couldn't do during the drive to the hospital. At the time it seemed more important to get there as fast as possible and the patient's private vehicle could get there faster because it would have taken time to arrange the EMS transport. The patient was instructed to travel in a reclining position while the spouse drove.

Review of physician #1's documentation, dated 4/27/17, revealed the following events occurred on 4/21/17: The patient was standing in the ED waiting area and showed his/her abdominal wound to physician #1. The wound was covered with a transparent occlusive dressing, and visible under the dressing was an incision partially covered by a gauze dressing and from the superior portion of the incision was a pink, smooth mass of tissue estimated to be 4 centimeters in diameter with the appearance of small bowel. A small amount of serous fluid was visible under the occlusive dressing. The patient conversed calmly and his/her color was good. The physician advised that immediate surgical care was required; and the patient needed to be seen by the surgeon at [hospital name]. The patient was advised to recline while the spouse drove.

Interview with patient #15 and spouse on 5/3/17 at 8:21 PM revealed the patient had abdominal surgery on 4/7/17 and was recovering at home without problems until 4/21/17. The patient stated s/he went to the ED on 4/21/17 because the surgical wound opened and internal organs protruding through the opening were visible through the occlusive dressing. The patient stated s/he did not refuse to be examined by physician #1 and the physician did not offer or suggest this. The patient stated physician #1 looked at the abdominal wound in the ED lobby and told the patient to have the spouse drive him/her to the hospital (over 100 miles away) because his/her condition required surgery. The patient's spouse stated the patient had been instructed to recline while traveling. They were not provided information about the risks versus benefits of traveling by private vehicle. The spouse stated they had traveled approximately 45 miles from the ED when the wound opening enlarged and a "large mass" of blood and fluid spilled into the occlusive dressing. The spouse stated, "we panicked, we did not know what to do." The spouse further stated the patient began to experience severe abdominal pain, they stopped traveling, and called EMS.

Review of the EMS report, dated 4/21/17, revealed the patient was unable to sit or ambulate due to severe abdominal pain; and s/he had abdominal distension with approximately 5 centimeters eviscerated bright red bowel protruding above the umbilicus surrounded by yellow fluid contained in an occlusive dressing. According the the EMS report, they started intravenous fluids, administered pain and nausea medication, connected the EKG monitor, and applied oxygen during transport to the hospital.

Review of the policy and procedure titled, "Patient Leaving Against Medical Advice (AMA)", revised April 2017, showed the following procedures will be instituted for a patient who expresses a desire to refuse or withdraw from a treatment or diagnostic study against medical advice or if a patient expresses a desire to leave the hospital AMA:
a. Request that patient discuss AMA decision with the physician. Notify the patient's physician/physician assistant of the Patient's desire to refuse or withdraw treatment/studies or leave the hospital AMA. The physician/physician assistant will discuss with the reason for the AMA decision and will advise the Patient of the potential consequences of the AMA decision. Reasonable efforts should be made to address any issues presented as reasons for the AMA decision.
b. The discussion should be documented in the medical record and include the patient's diagnosis; the reason for the patient's AMA decision; the benefits of following medical advice and the risks of not following; discharge instructions, including notation of any follow up visits or referrals and any prescriptions that were provided, should patient decide to leave; the offer for the patient to change their mind and either receive the treatment/study or return to the hospital; and have the patient sign the AMA form. If the Patient refuses to sign, read the form to the patient, make a specific notation of the patient's refusal to sign the form and have two witnesses sign the form as acknowledgement of the Patient's refusal to sign.
c. Nursing will document in the nursing or Emergency Room Notes all pertinent information concerning the patient's action. Include the Patient's stated reasons for refusal, withdrawal or leaving, quoted verbatim.
d. The witnessed release form is placed in the patient's chart and if the patient leaves AMA, discharge procedures are completed.