HospitalInspections.org

Based in interview and record review, the facility failed to obtain AMA consents for patients who refused ambulance transport to a receiving hospital for 2 of 34 sampled patients (Patients 43 and 65).

Findings:

1. Patient-43 was seen in the ED on 6/16/15 with a chief complaint of head injury 5 days previous from a fall from the roof of a car onto concrete slab. The patient's mother brought her in for further evaluation of head swelling with a "soft spot". The ESI was a level 3.

The ED physician discussed the case with the trauma doctor at Facility-D who agreed to accept the patient in transfer for evaluation. But the patient's mother refused ambulance transport. The ED physician documented: " Mother... refuses ambulance transport, so will sign out AMA and drive child there herself".

The medical record revealed transfer consent forms that stated the patient would be transported by private vehicle but there was not an AMA consent form.

The facility's policy and procedure titled, "Transfer of Individuals With Emergency Medical Conditions", revised 9/14, page 5 of 16, documented the following: "G. Individuals Determined to Have an Emergency Medical Condition But Refuse to Consent to Treatment or Transfer... 1(c)... A patient who has refused further medical examination and treatment shall be considered a discharge against medical advice and appropriate policies covering this type of discharge shall be followed...".

The facility's policy and procedure titled, "AMA (Against Medical Advice)Patients Signing Out", revised 3/12, page 2 of 2, documented the following: " 6. The patient shall be requested to sign the form 'Leaving Hospital Against Advice'. This form shall be kept in the patient's medical record".

During an interview on 7/28/15 at 11:28 AM, MD-3 stated if a patient refused a transfer with an ambulance, the patient's disposition would be an AMA and would document the reasons for patient's refusal.

During another interview on 7/30/15 at 12:10 PM, the ED Director agreed the AMA form should have been completed for Patient-34.





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2. Patient-65 was in the ED on 7/26/15, at 21:50 PM (9:50 PM),with a head injury from a fall from a bicycle. The ESI was a level 2.

During record review dated 7/26/15, at 23:13 PM (11:13 PM)," patient data sheet", indicated," patient left AMA MD explained all risks and patient insisted that he leave to go home."

During the same record review (as stated above), discharge instructions, indicated,"AMA form 2..." This medical record revealed no AMA form.

During an interview on 7/30/15, at 12: 10 PM, ED director, stated," I don't see the AMA form."