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Based on medical record review, staff interview, Emergency Department Logs, and review of facility policies and procedures the facility failed to ensure individuals that presented for medical examination and treatment were provided the risks and benefits of the examination and treatment or documentation of the reasonable steps taken to secure the individual's written informed refusal for two (2) of 24 records reviewed, (Patient Identifiers #1 and #2).

Findings include:

Refer to A2407.

Based on review of medical records, review of policy and procedures, Emergency Department log, and staff interview, it was determined the facility failed to ensure an individual that presented for medical examination and treatment was provided the risks and benefits of the examination and treatment or documentation of the reasonable steps taken to secure the individual's written informed refusal for two (2) of 24 patients sampled, (Patient Identifiers #1, #2).

Findings included:

Review of the facility policy, "Discharge of Patients & Discharge of Patients Against Medical Advice (AMA)," NCL0006, stated the depart process is documented in the medical record for patients leaving the hospital. The policy stated when the patient makes a decision to leave AMA, the physician (whenever possible) or another healthcare provider explains, the risks associated with leaving against medical advice and reasons for continuing care. The healthcare provider records the events in the medical record. Routine discharge care and instructions per the Discharge Process are provided if possible and applicable. If the patient refuses instructions or to sign the AMA form, document in the medical record accordingly.

Review of the facility policy, "Emergency Department - Left Without Treatment (LWOT)," BC-ED-122, stated after exerting due diligence in determining the patient has left the campus, patient is considered "LWOT." Document the circumstances surrounding the discovery of patient's departure and attempt(s) made to verify patient not in waiting room areas.

1. Review of the Emergency Department (ED) log revealed Patient #1 left the facility AMA on 4/04/2019. Review of the medical record for Patient #1 revealed the patient was triaged on 4/04/2019 at 6:11 p.m. with complaints of nausea, right flank pain and fever since yesterday.

Review of the medical screening exam revealed on 4/04/2019 at 6:11 p.m. the Physician's Assistant (PA) initiated an examination and noted the patient presented with right flank pain, nausea, and fevers since yesterday. The patient had a history of renal stones and urinary tract infection. The PA documented the exam was started and orders were initiated. There was no further documentation by the PA. Review of the record revealed no other healthcare provider documented the events at the time the care and services were initiated, the reason for the patient's decision to leave, or any attempt to inform the patient of the risks associated with leaving against medical advice and reasons for continuing care.

Interview with the Manager of Clinical Professional Practice on 10/23/2019 at 1:15 p.m. confirmed the above findings.

2. Review of the Emergency Department (ED) log revealed Patient #2 left the facility without treatment on 4/04/2019. Review of the medical record for Patient #2 revealed the patient arrived on 4/04/2019 at 6:23 p.m. with a complaint of a head injury.

Review of the medical record revealed a CNA (Certified Nursing Assistant) obtained the patient's height and weight at 6:27 p.m. and vital signs at 6:30 p.m. Review of the record revealed the Registered Nurse (RN) documented the patient left without treatment at 6:50 p.m. Review of the record revealed no evidence the circumstances surrounding the discovery of the patient's departure nor any attempt(s) made to verify the patient was not in waiting room areas.

Interview with the Manager of Clinical Professional Practice on 10/23/2019 at 1:25 p.m. confirmed the above findings.