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Based on policy review, medical record review, staff and physician interviews, the facility failed to comply with 42 CFR §489.20 and §489.24.

Findings include:

1. Based on facility policy review, medical record review, staff and physician interviews, the facility failed to ensure that a patient had been informed of the risks and benefits of medical examination and treatment refusal prior to facility departure for 1 of 21 sampled Emergency Department medical records reviewed. (Patient #6).

~ Cross refer to §489.24(d) Necessary Stabilizing Treatment for Emergency Medical Conditions - Tag A2407

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Based on facility policy review, medical record review, staff and physician interviews, the facility failed to ensure that a patient had been informed of the risks and benefits of medical examination and treatment refusal prior to facility departure for 1 of 21 sampled Emergency Department medical records reviewed. (Patient #6).

The findings included:

Review of the Medical Staff Rules and Regulations, last revised 03/12/2019, " ...STABILIZATION ... If a patient refuses to accept the proposed stabilizing treatment, the Emergency Department Physician, after informing the patient of the risks and benefits of the proposed treatment and the risks and benefits of the individual's refusal of the proposed treatment, shall take all reasonable steps to have the individual sign a form indicating that he/she has refused the treatment. The Emergency Department Physician shall document the patient's refusal in the patient's chart, which refusal shall be witnessed by the Emergency Department supervisor ... "

Closed medical record review of Patient #6 revealed a 22-year-old female who presented to the DED on 10/14/2022 at 2054. Medical record review revealed Patient #6 was documented as Left Prior to Triage at 2123. Medical record review for Patient #6 revealed there only a face sheet available for Patient #6. Review failed to reveal documentation of a MSE or refusal of stabilizing treatment. The facility failed to ensure that their Medical Staff Rules and Regulations policy was followed as evidenced by staff failing to ensure that the ED physician was notified /inform to patient #6 of the risks and benefits of the proposed examination and treatment, and the risks and benefits of the patient's refusal to an examination and treatment. Additionally, the facility staff failed to take all reasonable steps to have the sign the AMA forms once the staff determined the patient was leaving the facility on 10/14/22

Interview on 11/09/2022 at 1305 with Registration #3 revealed she recalled registering Patient #6. Interview revealed Patient #6 arrived ambulatory accompanied by two visitors. Interview revealed Patient #6 was registered and went to wait in the waiting room. Interview revealed Registration #3 did not see Patient #6 in visible signs of distress in the waiting room. Interview revealed Patient #6 was sitting with the two visitors eating food in the waiting room before ambulating into the triage room. Interview revealed Patient #6 came out of the triage room and spoke with the two visitors before leaving. Interview revealed Patient #6 did stop at the window to let Registration #3 know that they were leaving and going somewhere else. Interview revealed Patient #6 ambulated out of the facility accompanied by the two visitors. Interview revealed Registration #3 did not discuss risks and benefits with Patient #6, nor alert nursing staff before facility departure.

Interview on 11/09/2022 at 1005 with ED RN #1 revealed she recalled the triage of Patient #6 on the evening of 10/14/2022. Interview revealed that ED RN #1 received a call for a new patient over the radio. Interview revealed that one of the ED staff let her know that on-call ultrasound was unavailable. Interview revealed Patient #6 was ambulatory and came into the triage room. Interview revealed that ED RN #1 had Patient #6 stand on the scale and asked for her chief complaint. Interview revealed Patient #6 complained of stomach pain and that she was pregnant. Interview revealed Patient #6 was not experiencing vaginal bleeding or discharge and requested an ultrasound. Interview revealed that ED RN #1 told Patient #6 that they were happy to see her, but they did not have ultrasound available. Patient #6 asked ED RN #1 what services the facility could provide. Interview revealed ED RN #1 informed Patient #6 that the facility could provide a pelvic exam, urine/lab testing, and STD checks, but if an ultrasound was needed then Patient #6 would have to be transferred. Interview revealed that Patient #6 stated, "well, I know I'm going to need an ultrasound" and "well, I'm just going to go somewhere else." Interview revealed ED RN #1 told Patient #6 that the DED could still see her, but Patient #6 departed the facility. Interview revealed ED RN #1 did not explain the risks and benefits to Patient #6.

Interview on 11/09/2022 at 0940 with ED Director #2 revealed she was not present when Patient #6 presented to campus. Interview revealed that ED Director #2 was notified by Quality Director #4 about the incident. Interview revealed risks and benefits were not discussed with Patient #6 prior to departure from the facility. Interview revealed that the facility leadership started working on a plan of correction as soon as they were made aware of the incident. Interview revealed that reeducation was performed in person at the ED staff meeting and again via computer-based learning. Interview revealed new emphasis was placed on ensuring that nursing and providers performed risks and benefits with all of the patients prior to DED departure or documented the reason they were unable to have the discussion.

Interview on 11/09/2022 at 1040 with the Quality Director #4 revealed the facility was made aware of the incident involving Patient #6 by another facility on 10/18/2022. Interview revealed that Patient #6 had left Hospital A's DED and made the roughly 45-minute drive to Hospital B, delivered in-route, and experienced a fetal demise. Interview revealed that once notified, Quality Director #4 and the leadership team came together to investigate and create a plan of correction. Interview revealed that Quality Director #4 interviewed each staff member that was present on the night of 10/14/2022. Interview revealed that the only staff members that interacted with Patient #6 were Registration #3 and ED RN #1. Interview revealed risks and benefits were not discussed with Patient #6 prior to departure from the facility. Interview revealed that the facility had implemented several measures including education, new process flows, and monitoring, but the data had not been fully analyzed for trends yet.

NC00194200, NC00194160