HospitalInspections.org

25730

Based on interview, and record review, the hospital failed to comply with 489.24 when 1 of 21 sampled patients (Patient 2) left the ED without having a completed medical screening examination and stabilizing treatment. (A2407).

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25730

Based on interview and record review, the hospital failed to ensure that:

A. One of 21 sampled patients (Patient 2) had a complete medical record when the Leaving Hospital Against Medical Advice declaration form was not in the current ED (Emergency Department) medical record even though Patient 2 left the ED without having a completed medical screening examination and stabilizing treatment.

Findings:

A. Patient 2 was admitted to the ED on 1/4/12 for calf and ankle pain following an assault, and for loss of consciousness following the same assault. While meeting with the ED physician the patient demanded narcotic injections for his pain rather than Vicodin by mouth. The ED physician explained to the patient that the medical screening examination and the CT (computer assisted tomography) scan of his brain needed to be completed before giving him pain medications stronger than Vicodin. Patient 2 refused to continue with the examination and refused the CT scan. He requested and was given crutches and he left the ED without signing the "Leaving Hospital Against Medical Advice" form.

The ED Discharge Note written by the Registered Nurse (RN) on 1/4/12 at 7:31 PM indicated Patient 2 left the ED AMA (Against Medical Advice), crutch walking, alone, and without having discharge vital signs taken. There was no documentation indicating Patient 2 had refused to sign the "Leaving Hospital Against Medical Advice" form.

In an interview on 2/26/12 at 1:40 PM, the Senior Director reviewed Patient 2's ED record and stated there was no "Leaving Hospital Against Medical Advice" form in the record.

In an interview on 2/29/12 at 10:30 AM, the Senior Director stated that no completed "Leaving Hospital Against Medical Advice" form had been located for Patient 2.

Record review of the hospital policy and procedure Leaving Hospital Against Medical Advice, dated 6/11, stated the physician should see the patient before he leaves AMA and the nurse should have the declaration form "Leaving Hospital Against Medical Advice" signed by the patient before departure. The procedure stated the form was to be completed even when the patient refused to sign and such refusal had to be witnessed and documented on the form. The procedure also stated the physician was to complete a portion of the declaration documenting the date and time the ED physician "explained the risks and consequences of leaving, the benefits of continued treatment and hospitalization, and alternatives, if any." The procedure also stated the completed form was to be placed in the patient's ED record.

The hospital failed to ensure Patient 2's "Leaving Hospital Against Medical Advice" form was completed and stored according to its policy and procedure.