HospitalInspections.org

Based on interview and record review, a registered nurse did not supervise and evaluate 1 of 1 patient (Patient #1) who went against medical advice (AMA) on 05/03/23. The same registered nurse did not follow the hospital's required documentation when a patient would leave the facility AMA.

Findings included:

Patient #1 presented in the emergency department on the afternoon of 05/02/23 with a chief complaint of syncope and facial droop. She was subsequently admitted and was waiting for an available inpatient bed. A brief discharge note by Physician #6 dated 05/03/23 at 10:48 PM reflected "medicine team was notified Patient [#1] left AMA."

Per policy, there was no nursing note that indicated the following found in the medical record:
-the time the patient left
-mode of transportation
-physician notification
-patient's condition at the time of leaving AMA
-a filled out form of Release of Responsibility

During an interview on 10/02/23 at 11:41 AM in the quality conference room, Personnel #1 was asked to provide evidence of the above required information. Personnel #1 stated the nursing staff did not have enough documentation about the patient's AMA.

Policy and Procedure # PCS040 entitled "Against Medical Advice/Elopement..." date reviewed 03/05/2019 required "III...A. AMA/Elopement...7. Accurate and pertinent documentation of the incident is completed by the nurse. The nurse notes the time the patient leaves, mode of transportation and physician notification...The patient's condition at the time of leaving AMA/Elopement is documented. The Release of Responsibility form is placed in the patient's medical record."