HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 3 (Pt #1) sample patients, who signed out Against Medical Advice (A.M.A.), the Hospital, failed to ensure its' A.M.A. policy was followed.

Findings include:

1. The policy titled " Discharge Procedure: Routine and A.M.A. (Against Medical Advice) " was reviewed on 11/20/14 at approximately 1:30 PM. The policy stated " 3.0 B. 5. When patient/family refuses to sign a A.M. A. form, the nurse documents reason(s) in nurse ' s notes, two (2) nurses sign the A.M.A. form with reason stated on the form as to why patient/family refused to sign. "

2. Pt #1's record was reviewed on 11/19/14 at approximately 12:45 PM. Pt #1, a 67 year old male, was admitted to Same Day Surgery on 9/18/14 with the diagnosis of Left Upper Lobe Lung Mass and underwent a CT guided biopsy for lung lesion by MD #1. Pt #1 developed a Pneumothorax, had a chest tube and was admitted to inpatient status. On 9/20/14 at 7:20 AM, nursing documentation stated Pt walked past nursing station to elevator (#5 next to the nursing station), shouting profanity. Night nurse went to patient room and found " lines have been removed by the Pt except IV (intravenous) access " . The Day House Supervisor was notified, came to floor, attempted to remove IV, Pt refused, Security was notified, Supervisor eventually was able to remove IV access prior to Pt #1 leaving the hospital against medical advice. The record lacked documentation of an A.M.A. form.

3. An interview was conducted with the Director of Quality (E#1) on 11/20/14 at approximately 3:30 PM. E#1 reviewed the record of Pt #1 and verbally agreed there was no A.M.A. form present.


B. Based on document review and interview, it was determined for 1 of 3 (Pt #1) patients who signed out AMA, the Hospital failed to ensure its' occurrence/incident reporting process was followed.

Findings include:


1. The policy titled " Patient Care Improvement Reporting " was reviewed on 11/20/14 at approximately 1:10 PM. The policy stated " 3.1 Occurrence: Any clinical or other situation creating a potential for or actual harm, including unexpected treatment or care related outcomes ... 3.2.2. Any patient complaint about care rendered by physicians or hospital personnel ... 3.2.6 Also including but not limited to: a. discharge against medical advice ... "
The policy titled " Security Incident Report Writing " was reviewed on 11/20/14 at approximately 3:10 PM. The policy stated " All Security Mission Partners are required to fill out a Security Incident report on anything that is not routine. Routine defined as escorts, boiler room checks, locking and unlocking the buildings ... "

2. Pt #1's record was reviewed on 11/19/14 at approximately 12:45 PM. Pt #1, a 67 year old male, was admitted to Same Day Surgery on 9/18/14 with the diagnosis of Left Upper Lobe Lung Mass and underwent a CT guided biopsy for lung lesion by MD #1. Pt #1 developed a Pneumothorax, had a chest tube and was admitted to inpatient status. On 9/20/14 at 7:20 AM, nursing documentation stated Pt walked past nursing station to elevator (#5 next to the nursing station), shouting profanity. Night nurse went to patient room and found " lines have been removed by the Pt except IV access " . The Day House Supervisor was notified, came to floor, attempted to remove IV, Pt refused, Security was notified, Supervisor eventually was able to remove IV access prior to Pt #1 leaving the hospital against medical advice. The record lacked documentation of an A.M.A. form.

3. On 11/20/14 at approximately 11:30 AM, an interview was conducted with the Director of the Medical Surgical Unit (E#4). E#4 stated awareness of the occurrence/incident with Pt #1 and did not do an investigation as felt it would be unnecessary. E#4 stated "The patient had made ... own decision, pulled out everything in the room... got on the elevator and left." E#1 stated an occurrence/incident report should have been completed and E#1 and E#8 do the follow ups on these reports.

4. On 11/20/14 at approximately 12:10 PM, an interview was conducted with the Director of Quality (E#1). E#1 stated was unaware of the occurrence/incident with Pt #1 until today when surveyors arrived. E#1 stated E#1 spoke with Risk Management (E#8) and E#8 was also unaware of the occurrence/incident.

5. On 11/20/14 at approximately 3:08 PM, a phone interview was conducted with the President of the Medical Staff (MD#4). MD#4 was unaware of the occurrence/incident with Pt #1.

6. On 11/21/14 at approximately 7:50 AM, an interview was conducted with the Registered Nurse (E#2) who cared for Pt #1 on 9/19/14 PM to 9/20/14 AM. E#2 stated "I didn't think I needed to write an incident report because it wasn't an error on our part." E#2 listed events which would require a report and stated "not A.M.A."

7. On 11/21/14 at approximately 9:00 AM, an interview was conducted with the Day Shift Supervisor (E#4), who was involved during the time of Pt #1's leaving the Hospital. E#4 stated the nurse (E#2) should have done an incident report and wasn't aware a report had not been completed.

8. On 11/21/14 at approximately 11:25 AM, an phone interview was conducted with the Security guard (E#7), who was involved during the time of Pt #1 leaving the Hospital. E#7 was asked to be on the lookout for Pt#1 due to having intravenous (IV) access that needed to be discontinued. Security asked Pt #1 to wait for the IV to be discontinued, called the nursing staff, waited with Pt #1 until the nursing staff came and discontinued the IV, and watched Pt #1 leave the premises via a cab. E#7 stated Security doesn't' do an incident report for A.M.A.s unless their is a physical altercation of some sort we are involved in. ...(Pt#1) was leaving on his/her own accord against medical advice.

A. Based on document review and interview, it was determined for 1 of 3 (Pt #1) sample patients, who signed out Against Medical Advice (A.M.A.), the Hospital, failed to ensure its' A.M.A. policy was followed.

Findings include:

1. The policy titled " Discharge Procedure: Routine and A.M.A. (Against Medical Advice) " was reviewed on 11/20/14 at approximately 1:30 PM. The policy stated " 3.0 B. 5. When patient/family refuses to sign a A.M. A. form, the nurse documents reason(s) in nurse ' s notes, two (2) nurses sign the A.M.A. form with reason stated on the form as to why patient/family refused to sign. "

2. Pt #1's record was reviewed on 11/19/14 at approximately 12:45 PM. Pt #1, a 67 year old male, was admitted to Same Day Surgery on 9/18/14 with the diagnosis of Left Upper Lobe Lung Mass and underwent a CT guided biopsy for lung lesion by MD #1. Pt #1 developed a Pneumothorax, had a chest tube and was admitted to inpatient status. On 9/20/14 at 7:20 AM, nursing documentation stated Pt walked past nursing station to elevator (#5 next to the nursing station), shouting profanity. Night nurse went to patient room and found " lines have been removed by the Pt except IV (intravenous) access " . The Day House Supervisor was notified, came to floor, attempted to remove IV, Pt refused, Security was notified, Supervisor eventually was able to remove IV access prior to Pt #1 leaving the hospital against medical advice. The record lacked documentation of an A.M.A. form.

3. An interview was conducted with the Director of Quality (E#1) on 11/20/14 at approximately 3:30 PM. E#1 reviewed the record of Pt #1 and verbally agreed there was no A.M.A. form present.


B. Based on document review and interview, it was determined for 1 of 3 (Pt #1) patients who signed out AMA, the Hospital failed to ensure its' occurrence/incident reporting process was followed.

Findings include:


1. The policy titled " Patient Care Improvement Reporting " was reviewed on 11/20/14 at approximately 1:10 PM. The policy stated " 3.1 Occurrence: Any clinical or other situation creating a potential for or actual harm, including unexpected treatment or care related outcomes ... 3.2.2. Any patient complaint about care rendered by physicians or hospital personnel ... 3.2.6 Also including but not limited to: a. discharge against medical advice ... "
The policy titled " Security Incident Report Writing " was reviewed on 11/20/14 at approximately 3:10 PM. The policy stated " All Security Mission Partners are required to fill out a Security Incident report on anything that is not routine. Routine defined as escorts, boiler room checks, locking and unlocking the buildings ... "

2. Pt #1's record was reviewed on 11/19/14 at approximately 12:45 PM. Pt #1, a 67 year old male, was admitted to Same Day Surgery on 9/18/14 with the diagnosis of Left Upper Lobe Lung Mass and underwent a CT guided biopsy for lung lesion by MD #1. Pt #1 developed a Pneumothorax, had a chest tube and was admitted to inpatient status. On 9/20/14 at 7:20 AM, nursing documentation stated Pt walked past nursing station to elevator (#5 next to the nursing station), shouting profanity. Night nurse went to patient room and found " lines have been removed by the Pt except IV access " . The Day House Supervisor was notified, came to floor, attempted to remove IV, Pt refused, Security was notified, Supervisor eventually was able to remove IV access prior to Pt #1 leaving the hospital against medical advice. The record lacked documentation of an A.M.A. form.

3. On 11/20/14 at approximately 11:30 AM, an interview was conducted with the Director of the Medical Surgical Unit (E#4). E#4 stated awareness of the occurrence/incident with Pt #1 and did not do an investigation as felt it would be unnecessary. E#4 stated "The patient had made ... own decision, pulled out everything in the room... got on the elevator and left." E#1 stated an occurrence/incident report should have been completed and E#1 and E#8 do the follow ups on these reports.

4. On 11/20/14 at approximately 12:10 PM, an interview was conducted with the Director of Quality (E#1). E#1 stated was unaware of the occurrence/incident with Pt #1 until today when surveyors arrived. E#1 stated E#1 spoke with Risk Management (E#8) and E#8 was also unaware of the occurrence/incident.

5. On 11/20/14 at approximately 3:08 PM, a phone interview was conducted with the President of the Medical Staff (MD#4). MD#4 was unaware of the occurrence/incident with Pt #1.

6. On 11/21/14 at approximately 7:50 AM, an interview was conducted with the Registered Nurse (E#2) who cared for Pt #1 on 9/19/14 PM to 9/20/14 AM. E#2 stated "I didn't think I needed to write an incident report because it wasn't an error on our part." E#2 listed events which would require a report and stated "not A.M.A."

7. On 11/21/14 at approximately 9:00 AM, an interview was conducted with the Day Shift Supervisor (E#4), who was involved during the time of Pt #1's leaving the Hospital. E#4 stated the nurse (E#2) should have done an incident report and wasn't aware a report had not been completed.

8. On 11/21/14 at approximately 11:25 AM, an phone interview was conducted with the Security guard (E#7), who was involved during the time of Pt #1 leaving the Hospital. E#7 was asked to be on the lookout for Pt#1 due to having intravenous (IV) access that needed to be discontinued. Security asked Pt #1 to wait for the IV to be discontinued, called the nursing staff, waited with Pt #1 until the nursing staff came and discontinued the IV, and watched Pt #1 leave the premises via a cab. E#7 stated Security doesn't' do an incident report for A.M.A.s unless their is a physical altercation of some sort we are involved in. ...(Pt#1) was leaving on his/her own accord against medical advice.