HospitalInspections.org

16401

Based on review of the Emergency Department (ED) Central Log and interview, it was determined that the disposition of individuals seeking assistance in the ED was not consistently documented.

Findings include:
Review of the ED log on 7/24/15 for the period October 1, 2014 - July, 2015, noted missing dispositions for the months of October, November, December, January, February, April and July. This was brought to the attention of Staff #1 (MD-ED Medical Director). It was determined that the facility failed to consistently meet all the requirements for maintenance of ED central log.

Based on staff interview and review of medical records, it was determined that the facility did not effectively meet the requirements for providing necessary stabilizing treatment of patient presenting to the Emergency Department (ED). Specifically, (a) when the determination is made that there is a need for further medical examination and treatment and the individual refuses to consent for further evaluation/treatment, then the hospital takes all reasonable steps to secure the individual's written informed refusal, (b) the written informed refusal documentation indicates that the person was informed of the risks as well as the benefits of further examination, treatment, or both.
This was evident in three (3) of four (4) emergency department records reviewed for patients who left the ED against medical advice (AMA); MR's (# 1, # 2 and # 3).

Findings include:
MR # 1 was reviewed on 7/27 /2015 via electronic, and hard copy (certified copy) on 7/29/2015 at approximately 10:00 AM. It was noted that this 57 year old patient, with medical history of cardiovascular disease and hypertension, walked into the facility's ED on 2/11/2015 at 1:02 PM. The chief complaint was chest pain. The patient was triaged on 2/11/2015 1:09 PM and was assigned Triage Category ESI (Emergency Severity Index) 3- Urgent. Vital Signs: Temperature 96.7, Blood Pressure 165/88 & Respirations 23; Pain scale - 4/10 (on a pain scale of 1 to 10). An EKG (electrocardiogram) was performed on 2/11/2015 13:17 (1:17 PM); the medical screening was performed on 2/11/2015 2:46 PM. The Medical Diagnosis was Angina, Atypical Chest Pain. The disposition was "left AMA" (against medical advice). The physician documentation noted that the patient refused to wait one hour for labs results, "I oriented him about the risk of leaving the ED. He understands and still refuses to wait."
It was noted that the documentation did not include if the patient was informed of the benefits of staying for complete evaluation/treatment. In addition, a copy of the AMA form was not located in the record, to document that the facility had secured a written informed refusal from the patient.

MR # 2 was reviewed on 7/27/2015 via electronic, and hard copy (certified copy) on 7/29/2015 at approximately 10:05 AM. It was noted that this 26 year old female patient presented to the ED on 2/14/2015 9:17 PM. The chief complaint was pregnant with vaginal bleeding < 20 weeks. The patient was triaged on 2/14/2015 at 9:24 PM and assigned Triage Category ESI-3; Pain Score 2/10. The medical examination was performed on 2/14/2015 at 9:43 PM and a Transvaginal Ultrasound (US) was done, and the result showed large Subchorionic Hemorrhage. The physician noted that the patient decided to leave AMA without getting blood typing or repeat vital signs. The physician documentation noted "the patient was oriented about the importance of waiting for lab results but she refused to stay; she signed to leave against medical advice."
A copy of the AMA form which detailed the risks and benefits of the patient not staying for a complete evaluation and the informed refusal from the patient was not located in the record.

MR # 3 was reviewed on 7/27/2015 via electronic, and hard copy (certified copy) on 7/29/2015 at approximately 10:15 AM. This 54 year old patient with history of DVT/PE (Deep Vein Thrombosis/ Pulmonary Embolism) and Asthma, presented to the ED on 4/1/2015 at 4:28 AM with chief complaint of difficulty breathing and chest pain. The patient also complained of swelling of left leg x 4 days. The patient was triaged on 4/1/2015 at 4:35 AM; Vital Signs: Temperature 96.8, Blood Pressure 121/78, Respirations 20 & O2 98%; Pain Scale: 6/10 and was assigned category ESI 3- Urgent. The patient had a nursing reassessment on 4/1/2015 at 6:47AM and an EKG completed on 4/1/2015 6:51 AM. The physician examination was electronically signed 4/1/2015 08:02 AM. The discharge disposition was patient left AMA. There was a physician notation in the record, "signed AMA after explanation of possible chronic pain, permanent disability and and sudden death."
There was no documentation that the patient had an emergency medical condition and that the need for further evaluation/treatment was explained to the patient. It was also noted that a completed copy of the AMA form describing that the risks and benefits of further evaluation and treatment was discussed with the patient and the informed refusal from the patient, was not located in the record.

Staff #1 was interviewed on 7/29/ 2015 at 2:20 PM. This staff reviewed the medical records MR's (# 1, # 2 and # 3) and stated that he will follow-up with the necessary documents on 7/30/2015.
On 7/30/2014 at 12:15 PM, Staff # 1 provided this surveyor a copy of a "A Discharge from Hospital Against Medical Advice" form, dated 2/11/2015 and signed by the patient, MR #1. The language on the form is as follows: "This is to certify that I (am leaving the hospital/am taking ------ (patient's name written in blank space) against the advice of both attending physicians and hospital authorities." It was determined that the AMA forms given to patients does not meet the requirement of fully explaining to the patient the benefits and risks of leaving the hospital before a complete evaluation was done, instead, it is releasing all physicians and the hospital and its staff from any liability when the patient leaves before discharge.
It was also noted that the person who signed the "witness section" of the form did not complete the "relationship section" of the form.