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Based on a review of facility policies and procedures, medical records, and staff interviews, it was determined that the facility failed to provide an appropriate, ongoing Medical Screening Examination (MSE) for six (P#1, P#6, P#10, P#11, P#15, and P#16) of 24 sampled patients presenting with behavioral health complaints.

Findings included:

P#1 arrived at the facility emergency department (ED) on 7/19/24 at 7:30 p.m. with complaints of suicidal ideations as reported by emergency medical services (EMS) staff. A provider assessed P#1 at 10:22 p.m. P#1 was escorted from the premises at 11:00 p.m. after becoming aggressive with staff. A psychiatric or mental status examination was not performed.

P#6 presented to the facility's ED on 7/11/24 at 12:51 a.m. with a chief complaint of suicide. A review of an "Attending Physician Note" on 7/11/24 at 2:38 a.m. revealed that P#6 had suicidal ideations without a plan. After becoming verbally aggressive with the provider, P#6's disposition was documented as discharge on 7/11/24 at 2:42 a.m. The medical record failed to reveal further psychiatric or mental status examination by a provider.

P#10 presented to the facility's ED on 5/15/24 at 12:41 a.m. with a chief complaint of suicide and chest pain. Form 1013 (involuntary hold) was initiated after a provider assessment. The 1013 was rescinded by the subsequent provider. P#10's disposition was documented as against medical advice (AMA) and discharged on 5/15/24 at 8:10 p.m.

P#11 presented to the facility's ED on 5/7/24 at 3:24 p.m. with a chief complaint of psychiatric evaluation. The provider recommended treatment and admission. P#11's disposition was entered as an AMA from the facility on 5/8/24 at 3:09 a.m.

P#15 presented the facility's ED on 3/14/24 at 4:02 p.m. with a chief complaint of suicide. P#15 was discharged from the facility on 3/14/24 at 6:11 p.m. with discharge paperwork that had discharge instructions about alcohol use.

P#16 presented to the facility's ED on 2/2/24 at 9:59 p.m. with a chief complaint of a headache. The patient had a history of schizophrenia. P#16 was discharged from the facility on 2/3/24 at 1:23 a.m.

Cross refer to A2406 as it relates to the facility's failure to provide an appropriate, ongoing Medical Screening Examination (MSE) for P#1, P#6, P#10, P#11, P#15, and P#16.

Based on a review of facility policies and procedures, medical records, and staff interviews, it was determined that the facility failed to provide an appropriate Medical Screening Examination (MSE) for six (P#1, P#6, P#10, P#11, P#15, and P#16) of 24 sampled patients medical records reviewed that did not receive a comprehensive psychiatric evaluation, mental status examination by the emergency department provider or a consulting provider.

Findings Included:

Medical Record Reviews:

A review of Patient #1's "Emergency Medical Services Patient Care Record", dated 7/19/2024 revealed that his chief complaint was suicidal ideations (SI) (thoughts of harming self) and foot pain. The local fire department communicated to EMS that reported that P#1 wanted to kill himself by overdosing on fentanyl. The patient reported SI with a plan to overdose. The patient admitted to drug use and alcohol use. The patient had outbursts of being agitated and punching on the jumpbag. The patient was placed on the stretcher. The patient agreed to wear the pulse oximeter. The patient refused blood pressure or other vital sign assessments, while en route. The patient did not answer being asked if he had homicidal ideation (HI) (thoughts of harming others). The patient was transported nonemergent to a facility where transfer of care was given to a registered nurse (RN). Further review revealed that P#1 had been released on 7/11/24 from an inpatient behavioral health facility for HI.

A review of P#1's medical record from Facility #1 revealed that P#1 was a 51-year-old male who was admitted to the facility on 7/19/24 at 7:30 p.m. with a chief complaint of insomnia. P#1 had a past medical history of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hypertension (high blood pressure), and schizophrenia (a serious mental health condition that affects how people think, feel and behave).

A further review of P#1's medical record revealed that P#1 was negative for self-injury or SI.

Continued review of P#1's record, dated 7/19/24 at 7:53 p.m., revealed that a suicide risk assessment of P#1 was attempted, and P#1 refused to answer the assessment questions.

A review of "ED Triage Notes", dated 7/19/24 at 7:46 p.m., revealed that P#1 reported that he was cold and wanted to rest. No acute respiratory or other acute distress is noted. P#1 was uncooperative and agitated and the charge nurse was notified. P#1 refused to get off of the EMS stretcher and into a wheelchair. He also refused to answer additional questions. The EMS crew reported that P#1 endorsed SI. The provider assessed the P#1 at 8:00 p.m. The provider reported that P#1 did not express SI and if the patient was truly suicidal, he needed to be evaluated for that. P#1 continued to refuse to answer screening questions and P#1 was moved to hallway 6. P#1 will be monitored until he is transported to his room assignment.

Further review revealed at 8:30 p.m., P#1 refused a vital sign reassessment. Continued review of P#1's record revealed that P#1 refused to answer assessment questions for a suicide risk assessment at 7/19/24 at 8:36 p.m. Review of "ED Notes", dated 7/19/24 at 9:22 p.m., revealed that P#1 refused a vital sign assessment. At 9:31 p.m., P#1 refused to answer questions and refused to uncover his face. Monitoring was ongoing with a sitter at the bedside.

A review of "ED Care Timeline", dated 7/19/24 at 10:22 p.m., revealed that a medical screening examination (MSE) was conducted by a Medical Doctor (MD). P#1 informed the physician that he had been having difficulty sleeping and that he (P#1) was tired of hearing voices. P#1 denied SI or HI. The psychiatric / behavioral evaluation included in the review of systems revealed that P#1 was positive for hallucinations and sleep disturbance and negative for suicidal ideations.

A review of "ED Notes", dated 7/19/24 at 10:47 p.m., revealed that P#1 reported hallucinations and reported that his medication was stolen. The provider was notified that P#1 refused to answer questions. On 7/19/24 at 11:00 p.m. P#1 became agitated and started screaming at the registered nurse (RN) using derogatory language and racial slurs. Public safety responded to P#1's bedside. The provider was notified. The patient had no complaints and denied SI and HI. P#1 did not appear acutely psychotic and was safe for discharge. Further review of "ED Notes" on 7/19/24 at 11:00 p.m., revealed that P#1 was physically abusive to the public safety officers and was escorted out of the treatment area by public safety officers.

P#1 was discharged home on 7/19/24 at 11:21 p.m. with a final diagnosis of insomnia and schizophrenia. A review of the "ED Provider Note" dated 7/20/24, revealed that P#1 was doing well at the time and had been sleeping. P#1 was offered food and olanzapine (an antipsychotic medication that is used to treat schizophrenia and bipolar disorder) to help with sleep. Patient became agitated and belligerent with the nurse using foul language. Public Safety was called escorted P#1 off the premises.

A review of P#1's medical record from Facility #2 revealed that P#1 was a 51-year-old male was admitted to the facility on 7/23/24 with a chief complaint of suicidal ideations and hallucinations.

A telephone interview was conducted on 8/1/24 at 10:02 a.m. with Registered Nurse (RN) BB, RN BB said she recalled P#1 being brought to the facility by Emergency Medical Services (EMS) because it was around shift change. RN BB recalled that P#1 refused to get off the EMS stretcher therefore she went outside to conduct her triage assessment of P#1. She said that EMS stated to her that P#1 was brought in with a chief complaint (CC) of suicidal ideation (SI) with a plan. RN BB explained that EMS staff were unable to elaborate on the specifics of P#1's suicide plan was. RN BB explained that she conducted her assessment and made triage decisions based on information obtained from the patient directly including vital signs.

RN BB said she asked P#1 if he was suicidal and he told her, "No. I just want to sleep. I have been hearing voices and I can't sleep". RN BB added that P#1 pulled the blanket over his eyes and refused to answer any further questions. RN BB changed the chief complaint from suicidal ideations to insomnia. She added that his chief complaint was insomnia, and he never verbally expressed a desire to commit suicide. P#1 continued to refuse to get off the stretcher and the charge nurse was notified. RN BB said a provider went outside and was unsuccessful in completing P#1's assessment due to his uncooperativeness. Nearly an hour later they were able to bring P#1 into the facility. RN BB was aware that P#1 had a history of psychological issues and initiated a psychological protocol in case the provider ordered one. The psychological protocol included blood work, 15-minute checks, and public safety notifications. RN BB attempted to perform a suicide risk assessment several times, but P#1 refused to answer the questions. RN BB stated she was not present for P#1's discharge and never saw when public safety in Zone 1.

A telephone interview was conducted on 8/1/24 at 10:30 a.m. with RN CC. RN CC said she recalled P#1 coming in through the EMS bay and that security was nearby because P#1 had refused to get off the stretcher. She said P#1 was brought in for a mental health evaluation due to SI and homicidal ideations (HI). She recalled asking P#1 if he wanted to harm himself and he replied, no. She said that when she got to the third or fourth question of the suicidal risk assessment, P#1 quit talking. RN CC recalled that P#1 was very short with the provider. The provider informed P#1 if he (P#1) was not suicidal now that she would have to discharge him. RN CC said that P#1 became verbally abusive and threatening. RN CC explained to P#1 that she would prepare him for discharge after which P#1 became increasingly agitated and began calling her racial slurs. RN CC said when P#1 began making racial remarks towards her and his aggression escalated, she called public safety because she was concerned for her safety. RN CC did not know the exact process for how staff should handle abusive patients. She said she typically escalates an aggressive situation to her Charge Nurse and Security. RN CC did not observe staff physically cause harm to P#1; they only escorted him off the property. She explained that the discharge process for behavioral health patients depended on the situation. Providers initiated a 1013 hold if patients exhibited true expressions of SI/HI. If a patient was overly aggressive or not cooperative with the provider, the patient would be discharged.

A telephone interview was conducted on 8/1/24 at 11:15 a.m. with Medical Doctor (MD) DD. MD DD stated that she could not remember very much about P#1. MD DD took some time to review P#1's MR and recalled P#1 presenting with a chief complaint of insomnia but did not recall much interaction that she had with P#1. MD DD recalled that P#1 had become agitated and abusive towards staff, and security had to be called. MD DD did not feel that sedation was appropriate for him. She said that when she spoke with P#1 he seemed calm and had a clear thought process. She said she asked P#1 if he felt suicidal, and he responded, no but refused to say much beyond that so she had no choice but to discharge him. MD DD said she was unaware that P#1's chief complaint on arrival was SI with a plan. She added that the triage nurse would have been the one to change the chief complaint on the record prior to her assessing P#1. MD DD explained that when she reviewed P#1's record she was aware that a week prior he had been released from an inpatient behavioral health facility for SI/HI, but she assumed since he was recently released that he was stable because the facility had discharged him and gave him medication for his condition. She added that P#1 did not have any complaints about SI as far as she knew because his chief complaint was insomnia and that is what she assessed him for. MD DD said that when she assesses a patient with SI/HI, she assesses the patient's presentation, psychosis, and forward-thinking. In addition, she considered the patient's past medical history and patient interactions with staff. If the patient was aggressive, she tried to talk the patient down, continue their care, and offer them food, whatever would de-escalate the situation. If the patient remained aggressive sometimes, she medicated them, or restrained them if violent and had security alerted if they are a threat to themselves or staff.

A review of P#6's medical record revealed that P#6 presented to the facility's ED on 7/11/24 at 12:51 a.m. with a chief complaint of suicide. A review of an "Attending Physician Note" on 7/11/24 at 2:38 a.m. revealed that P#6 had suicidal ideations without a plan. Continued review revealed that P#6 got verbally aggressive with the physician and public safety was notified P#6 was escorted off the premises. Continued review of the medical record failed to reveal further psychiatric or mental status examination by a provider. P#6's disposition was documented as discharge from the facility on 7/11/24 at 2:42 a.m. The medical record failed to reveal further psychiatric or mental status examination by a provider.

A review of P#10's medical record revealed that P#10 presented to the facility's ED on 5/15/24 at 12:41 a.m. with a chief complaint of suicide and chest pain. Continued review of the medical record revealed that a physician had concerns that P#10 was experiencing acute psychosis and placed P#10 on a 1013 hold (involuntary temporary hold)., A psychological exam and mental status examination on 5/15/24 at 6:57 a.m. A new provider assumed P#10's care at 5/15/24 at 7:00 p.m. Continued review of the medical record revealed P#10 was removed from the 1013 hold on 5/15/24 at 7:55 p.m. by a provider. A review of an "ED Note" dated 5/15/24 at 7:56 p.m. by an RN revealed that P#10 requested to leave the facility because he felt that he was not being helped P#10 got up aggressively toward the RN yelling. The RN notified the provider.

Continued review of the medical record revealed that on 5/15/24 at 7:56 p.m. a provider documented that P#10 was calm and did not currently appear to be severely disorganized. There was no justification for using chemical or physical restraints and allowed P#10 to leave against medical advice (AMA) and that P#10 could return at any time for further concerns. P#10's disposition was documented as AMA and discharged on 5/15/24 at 8:10 p.m. Continued review of the medical record failed to reveal an AMA form on file. There is no assessment of patient insight or judgment. There are no questions regarding potential delusions, hallucinations, or paranoid thoughts. The thought process is not noted, and there are no further questions about suicide ideation, the duration of those thoughts, or further plans. No further questions are found regarding homicidal ideation or whether he has harmed others before.

A review of P#11's medical record revealed that P#11 presented to the facility's ED on 5/7/24 at 3:24 p.m. with a chief complaint of psychiatric evaluation. The history of present illness documented, "...presents to the emergency department after being found at Marta trying to assault and playing and acting aggressively. He was reported to have been punched in the face. EMS administered 5 mg of Versed and 5 mg Haldol IM. No other known medical history. Upon my evaluation, patient is somnolent but states his name. He has signs of head trauma on my examination..." The physical exam documented, "...left periorbital ecchymosis and peri-orbital edema..." A cervical collar was applied.

The medical record documented at 2:06 a.m., "...acute displaced fracture of the ramus of the right mandible with associated soft tissue swelling. Patient signed out to [ED MD 2] pending reassessment of mental status and mandibular fracture consult as needed."

A review of an "ED Provider Note" on 5/8/24 at 3:09 a.m. revealed that the RN observed that P#11 had ambulated toward the exit and asked P#11 to return to the patient room. Continued review revealed that at 3:20 a.m. the provider highly suspected P#11 had mental illness and would require a psychiatric admission. The provider discussed treatment and admission and P#11 was not interested. P#11 eloped from the ED. P#11's disposition was entered as an AMA from the facility on 5/8/24 at 3:09 a.m. Continued review of the medical record failed to reveal an AMA form on file. Continued review of the medical record failed to reveal a psychiatric or mental status examination documented by a provider. Additionally, there was no physical evaluation of the cervical, thoracic or lumbar spine to evaluate for injury post-trauma.

A phone interview was conducted with RN XX on 8/7/24 at 1:45 p.m. RN XX stated that they worked in the Emergency Department (ED) from 3 p.m. to 3 a.m. on the day of the incident and remembered P#11. During that time, RN XX explained that they were new graduate nurses working with a preceptor. They were not the patient's primary nurse. RN XX recalled that P#11 was brought in by Emergency Medical Services (EMS) with a cut on their forehead. RN XX stated that the patient recalled that the incident started at a cellular store where an employee at the store had thrown something at P#11. EMS picked P#11 near the MARTA station. RN XX recalled that P #11 was confused and yelling at everyone. P#11 was in the medical area of the ED in zone 3 -room 49, which only has curtains and no doors. P#11 was asleep most of the shift. Around 3:00 a.m. P#11 stated they wanted to leave. RN XX was told by MD WW to remove P#11's Intravenous Line (IV). P#11 was acting aggressively, walking around and yelling at others. RN XX was instructed to call security. P#11 left before security arrived. RN XX stated that the ED does have an Against Medical Advice Form (AMA) used when a patient has been seen by the MD but has decided to leave the hospital. In this situation, RN XX stated she was in the process of filling out the form when P#11 left the ED. MD WW did not attempt to talk with P#11 when they were informed P#11 requested to leave. RN XX explained that they had been told to call security if a patient became aggressive because staff have been hurt in the past. RN XX further explained that the Charge Nurse: "Just let them go." And explained the ED can't hold someone against their will. RN XX stated they were told that you can't 1013 a patient unless they are suicidal.

A telephone interview was conducted on 8/7/24 at 2:45 p.m. with MD WW. MD WW recalled some information about P#11. MD WW stated that P#11 did not start off in the mental health area and was sedated. She recalled that P#11 was waiting to be seen by a specialist for a fracture. P#11 was agitated and did not want to wait. MD WW recalled thinking P#11 was homeless and was concerned if he left that, he would not follow up for care. MD WW stated that a closed fracture like P#11's had been not emergent and would not have required immediate surgery. MD WW stated that when there is a patient with mental health issues, MD WW would assess the patient's risk for harm to self or others. MD WW stated that she evaluates a patient's agitation to ascertain if they are psychotic or just do not want to be treated. She added that when a patient wants to leave, that she cannot hold the patient against their will. MD WW believed that P#11 would not stay and felt there was no clear justification to hold him. MD WW explained she uses the AMA form after she has met with the patient and explained the risks and benefits and the patient still wants to leave. MD WW tries not to use the form on a standard basis and prefers to discharge patients and provide them with prescriptions and follow-up care rather than signing them out of AMA. MD WW recalled that P#11 had just walked out of the ED before any further discussion could be conducted. MD WW added that the facility is aware of the increase in mental health patients.

A review of P#15's medical record revealed that P#15 presented the facility's ED on 3/14/24 at 4:02 p.m. with a chief complaint of suicide. P#15 was assigned an acuity level of two. Review of the medical record revealed that P#15 had visual hallucinations, suicidal ideations, was positive for alcohol use, and requested information for alcohol rehabilitation. Continued review of the medical record revealed that P#15 wished to be dead in the past month, had non-specific active suicidal thoughts in the past month, and suicidal behavior. Continued review of the medical record revealed that P#15 had a Columbia Suicide Severity Rating Scale (CSSRS) risk as moderate. P#15 was discharged from the facility on 3/14/24 at 6:11 p.m. with discharge paperwork that had discharge instructions about alcohol use. Continued review failed to reveal any rehabilitation recommendations. P#15's record failed to reveal a psychiatric or mental status examination.

A review of P#16's medical record revealed that P#16 presented to the facility's ED on 2/2/24 at 9:59 p.m. with a chief complaint of a headache. P#16 was assigned an acuity level of four. P#16 had a past medical history of schizophrenia (a mental health condition that affects how an individual behaves, thinks, and feels). A physician note revealed that the headaches were likely part of delusions due to schizophrenia. P#16 was discharged from the facility on 2/3/24 at 1:23 a.m. Continued review of the medical record failed to reveal a psychiatric or mental status examination by a provider.

A telephone interview was conducted on 8/8/24 at 3:22 p.m. with MD BBB. MD BBB stated that he along with other physicians has spoken to the United Nursing Director (UND) KK, the ED Medical Director (EMD) LL, and the Assistant Medical Director, as well as the facility Chief Executive Officer and Vice Chair of Operations, about the dangerousness of Zone 1's behavioral health hallway area where the psychiatric patients are being placed in the hallway and not in private rooms. MD BBB stated that the nurses sit back with no security for both patients and the staff have no safe exit if events escalate. MD BBB is concerned that despite other Physicians also expressing their concerns, no changes have been made to protect staff and patients. MD BBB is concerned that staff and patients are at risk of harm. MD BBB further explained that there is no designated space to talk privately to these patients, who need to be interviewed in a private area and preferably not out in the open. This only adds to the difficulty of providing quality care to these patients. MD BBB says the setup for the psychiatric patient is not conducive to providing quality care with the privacy and protection needed for both patients and staff. MD BBB discussed that staff can only call security for an escort out of the ED if staff and patients are threatened and they are unable to safely provide care.

Policies and Procedures:

A review of the facility's policy titled, "[Emergency Medical Treatment and Labor Act ] EMTALA - Medical Screening, Treatment and Related Issues", no number, last reviewed 10/20/2016. The scope includes all EHC workforce members, including employees, volunteers, house staff, and medical staff members. Staff members are responsible for adhering to these guidelines in their interactions with patients, families, visitors, or any individual who comes to the EHC facilities.

Purpose:
The policy sets forth procedures to ensure that the Hospital meets all the requirements set forth in the Emergency Medical Treatment and Labor Act ("EMTALA)

Policy:
Any individual who comes to the Emergency Department (ED) or Labor & Delivery (L&D) requesting care should be offered an appropriate Medical Screening Examination (MSE) to determine if the individual has an Emergency Medical Condition (EMC). If an EMC exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the Hospital Policy on Transfers.

The Hospital should:

1. Provide an appropriate Medical Screening Exam to anyone coming to the Emergency Department or Labor & Delivery seeking medical care for a suspected Emergency Medical Condition;

Procedure:
An appropriate Medical Screening Examination should be provided to any individual who comes to the Emergency Department (and/or on Hospital Property} and:

(1) the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition or

(2) it is apparent that the person needs an examination or treatment of a medical condition based on the individual's appearance or behavior.

Medical Screening Examination

1. "Medical Screening Examination" or ("MSE") means the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not the patient has an Emergency Medical Condition.

An MSE is not an isolated event. It is an ongoing process that begins but does not end with Triage. Triage entails the clinical assessment of the individual's presenting signs and symptoms in order to prioritize when the individual will be seen by a physician or other QMP.

All individuals coming to the ED should be provided an MSE appropriate to the individual's presenting signs and symptoms, as well as the capability and capacity of the Hospital.

Depending on the individual's presenting signs and symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures, such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans, and/or other diagnostic tests and procedures. In making a decision regarding any MSE and whether an individual has an Emergency Medical Condition, the physician or other QMP should take into account the assessment of a triage nurse or other medical personnel and/or any information obtained from any other action taken as part of the MSE which may include, but is not limited to, laboratory results or diagnostic tests.

2. The medical record should reflect continued monitoring according to the individual's needs until it is determined whether or not the individual has an EMC and, if he/she does until he/she is stabilized or appropriately transferred. There should be evidence of this ongoing monitoring prior to discharge or transfer.

5. The ED attending physician and the ED Charge Nurse are accountable for determining the order in which patients receive an MSE and for ensuring that an MSE is performed.

7. Individuals with psychiatric symptoms: The medical records should indicate both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes is to determine if the psychiatric symptoms have a physiologic etiology. The psychiatric MSE includes an assessment of suicidal or homicidal thoughts or gestures that indicates danger to self or others.

Refusal of Examination or Treatment
1. There are two designations given to a patient when refusing examination and/or treatment:

a. Left Without Being Seen (LWBS)- Patient left the emergency department or L&D prior to Medical Screening Exam {MSE).

b. Against Medical Advise (AMA)- Patient leaves the hospital, emergency department or L&D after the MSE is performed.

If at any time during an ED or L&D visit, a patient refuses an MSE and/or treatment or leaves the ED or L&D before the examination and/or treatment can be completed, the ED or L&D personnel should make every attempt to inform the patient of the risks of refusing examination and/or treatment or of leaving before the examination and/or treatment can be completed. The staff's attempts to inform the patient of the risks should be documented in the medical record. If possible, the patient should be asked to wait for the physician or QMP, who can discuss the risks of leaving the Hospital with the patient.

If the patient decides to leave prior to the completion of his/her care, all efforts will be made to provide information, resources, and follow-up to assist in ongoing wellness.

2. The circumstances of the patient's refusal or departure should be documented in the medical record and the hospital, ED or L&D staff should take every reasonable step to complete and have the patient sign a Refusal of Examination/Treatment Form if the patient leaves without being seen (LWBS) or AMA.

If the patient refuses to sign a Refusal of Examination/Treatment Form or leaves before one can be prepared prior to the patient's departure, the Form should still be completed and annotated with (1) the date and time of the request for signature from the patient; and (2) when the patient left. This should be made part of the patient's medical record.

A review of the facility's policy titled, "Unauthorized Departure: Discharge of Patient Against Medical Advice (AMA) / Elopement / Left Without Being Seen (LWBS) no policy number, last reviewed 4/13/2022 purpose was to establish standardized processes when an adult patient with or without decision-making capacity elects to leave or seeks discharge against medical advice (AMA) from inpatient units, the Emergency Department (ED) and Labor & Delivery (L&D) or has left without being seen (LWBS).

Section 1. Patients with decision-making capacity who wish to leave an inpatient unit, the ED, or L&D Against Medical Advice (AMA).

Under Georgia law, a patient is deemed unable to make decisions for himself or herself if a licensed physician personally examines the patient and documents in the medical record that the patient lacks sufficient understanding or the capacity to make significant responsible decisions regarding his or her own medical treatment OR lacks the ability to communicate such decisions by any means. It is the physician's responsibility to determine and document the patient's capacity.

Please see Section II below regarding Elopement Precautions for patients who lack decision-making capacity for their own or others' safety.

See Section III below regarding patients in the Emergency Department or Labor and Delivery who Leave Without Being Seen (LWBS) before a Medical Screening Exam can be done.

PROCEDURE:

I. Patients with decision-making capacity (AMA Discharge)

1. When a patient informs a member of the staff that he/she is leaving, the patient's physician or advanced practice provider (APP) and the charge nurse are notified of the patient's intent to leave and the reason(s) why.

2. The clinical provider assesses the patient's medical decision-making capacity and discusses with the patient the risks of staying or leaving, including the risks of having or not having treatment.

4. The nurse, physician, or APP informing the patient of risks will document in the patient's medical record the following information:
* the potential risks of leaving AMA
* discharge instructions (limited to the extent the patient has not had a full workup, but at a minimum, will offer to resume treatment if they return)
* any prescriptions

5. The physician, APP, nurse, or designee requests that the patient read and sign the form entitled "Release of Patient Against Medical Advice,"

6. In the event the patient or parent/guardian, if applicable, refuses to sign the form, this fact should be noted on the form and the witnesses present when the form was offered must sign their complete names and include the date. The original form is placed in the patient's medical record.

7. Staff will complete a SAFE report for inpatient AMA Discharges.

8. For patients with capacity that leave with or without notifying staff from the Emergency Department or Labor & Delivery, steps 4 - 7 should be followed. Patients that leave AMA should be given discharge instructions and any appropriate prescriptions or supportive care items and follow the standard protocol of AMA discharge in the electronic medical record system.

II. Patients without decision-making capacity, suicidal or require involuntary psychiatric evaluation or treatment (Elopement)

1. Medical Decision-Making Capacity Determination: When there is a reasonable concern for the immediate safety of a patient, a licensed physician or APP who has personally examined the patient should determine if the patient lacks sufficient understanding or capacity to make significant responsible decisions regarding his or her medical treatment and obtain consent from an authorized surrogate. If a person authorized to consent is not readily available, based on implied consent, the physician must follow the Emory Healthcare Restraint policy when "any delay in treatment could reasonably be expected to jeopardize the life or health of the person affected or safety risk could reasonably result in disfigurement or impaired faculties." (Emergency treatment statute at OCGA 31-9-3.)

2. For suicidal patients, non-suicidal patients requiring involuntary psychiatric evaluation or treatment, or safety risk patients determined to lack medical decision-making capacity on elopement precautions who attempt to leave the hospital, implement Medically/Non- Violent/Therapeutically Unsafe/ Disruptive Behavior Restraints. If behavior escalates and or forced medication administration must occur, implement Violent or Self-Destructive Behavior/Seclusion Restraints. (Reference the Restraint Policy and Safety Behavioral Assessment and Policy).

3. If such a patient departs undetected (Elopement), then the Security Alert - Missing Inpatient response protocol should be followed (refer to policy "Security Alert - Missing Inpatient").

4. Staff will complete a SAFE report for all elopements as part of the Security Alert - Missing Inpatient Protocol.

5. This process for patients that elope is the same for inpatients, ED, and L&D patients.

III. Left Without Being Seen (LWBS) in the Emergency Department and Labor & Delivery

1. In the ED and in L&D, if a patient leaves before the Medical Screen Examination is initiated by the designated medical staff provider, i.e. the patient has Left without Being Seen (LWBS), the care team will document in the record that the patient left and discharge as a LWBS in the electronic medical record. Refer to the policy: EMTALA-Medical Screening, Treatment, and Related Issues ("Refusal of Examination or Treatment" section).

A review of the facility's policy titled "Safety Risk: Assessment, Precautions & Interventions for P