HospitalInspections.org

Based on surveyor review of medical records, facility grievances, facility incident reports, interviews, and hospital policies and procedures, the facility's nursing staff failed to ensure patient #1's plan of care was complete and accurate, reflecting patient #1 physiological needs.

The findings include:

1. The facility failed to follow their Discharging Patients from Facilities- includes Against Medical Advice policy, which reads [in part] as follows:


"It is the responsibility of the licensed nurse or provider in the ED [emergency department] to obtain a patient's signature on the Release. . . form. Notify the practitioner of the patient's condition and reasons for wanting to leave. Licensed staff in the ED is responsible for informing the AMA patient of . . . Assurance of available medical care in the ED, need to seek timely medical attention, risk of leaving. . .If the patient refuses to sign the AMA form, the nurse will document the facts in the clinical records. Document the date and time authorized prescribing practitioner was contacted and objective information leading to the patient's departure in the clinical record. "


~The facility failed to provide an AMA form signed by patient #1.

~The facility failed to provide nursing or provider documentation that patient #1 was given an AMA form and refused to sign the AMA form.

~The facility failed to provide documentation that patient #1 received education on the risks of leaving AMA and the benefits of staying hospitalized.

~On 5/7/21 at 1:30 pm, staff #4 documented, "RN [registered nurse] advised pt [patient] that if he [the patient] w [was] not satisfied with the care he [the patient] was getting that he did not have to stay."

2. The nursing staff failed to adequately document reassessments vital sign data (including oxygen administration) for patient #1.

~Patient #1 had one set of vital signs documented on 5/7/21 at 1238 pm, which indicated his heart rate was critically low at 21 bpm (beats per minute). Patient #1 had no additional vital signs documented for his eight-hour hospital stay.

~The nursing staff failed to correct the inaccurate documentation if 21 bpm was, in fact, a documentation error, intervene appropriately if patient #1's heart rate was accurately measured at 21 bpm, and reassess patient #1 after the intervention, or monitoring patient #1 for additional trends in vital signs.

~The nursing staff failed to accurately document the application and continued usage of supplemental oxygen on patient #1.