HospitalInspections.org

Based on medical record review and staff interview , it was determined that the facility did not effectively ensure that individuals who needed further specialty evaluation/consultation were provided care consistent with the prevailing standards of medical practice. This finding was noted in 2 of 4 applicable records reviewed.

Findings include:
Review of MR #6 this patient a 51 year old arrived to the Emergency Department (ED) on 10/3/11 at 02:53 ambulatory complaining of being depressed. The past medical history includes chronic back pain, depression and hemorrhoids. The vital signs taken at 02:57 noted B/P: 161/100, P: 98, RR: 16, T: 98.3. There is no documentation that the patient had a specialty consultation/evaluation based upon the chief complaint and no reassessment of the patient with a blood pressure of 161/100.
Review of MR #7 this 65 year old patient arrived to the ED on 11/2/11 at 12:41 from the methadone clinic with a history of hypertension, CHF, Cellulitis and hip replacement with chief complaint of being suicidal. Vital signs noted B/P: 129/80, P: 80, R: 16, T: 98.0. There is no documentation that this patient received a specialty consultation/evaluation based upon his chief complaint.
The Administrator was interviewed on 12/28/11 at approximately 4:30 PM. This staff reported that she went to the medical records department but there were no other papers/documents in the paper records that indicated that these patients had specialty consultations/evaluations.

Based on medical record review and staff interview it was determined that the facility did not effectively ensure that individuals who needed further medical examination and treatment but refused the treatment/examination that the facility secure written refusal from these individuals (or person acting on the individual's behalf). This finding was noted in five of seven applicable records reviewed (MR#s 1-5)

Findings include:

Review of MR #1 noted that this patient was a 55 year old patient who was brought to the facility's Emergency Department ( ED) by ambulance on 11/1/11 at 08:06. The presenting symptom was hypoglycemia .Past history included: DM, hypertension, CAD and COPD. VS: 202/93, P 37, R 16 & T 96. The physican noted that the patient refused EKG/FS or further work-up. The physican noted that "the patient understood my explanations of the risks of the decision to leave the hospital against medical advice. There was no documentation that the physican attempted to secure the patient's written refusal as per facility's policy " Discharge Against medical Advise. "

Review of MR # 2 noted that this patient 67 year old with history of asthma, hypertension, and high cholesterol was brought to the facility's ED by ambulance on 11/06/11. The chief complaint was shortness of breath, dizziness and chest pain. VS: BP 160/90, P 81, R 20, T 96.1. It was noted that the patient had a physical examination and the plan was cardiac labs and admit. The physician noted that the patient decided not to stay for a second cardiac enzyme test or admission. The physician documented that the risks of the decision to leave against medical advice was explained to the patient. There was no documentation that the physician attempted to secure written documentation indicating that the patient had been informed of the risks and benefits of leaving the hospital without further evaluation.


Review of MR# 3 noted the patient a 48 year old arrived to the ED on 10/28/11 at 15:21 via ambulance complaining of chest pain. The past medical history is significant for atrial fibrillation, atrial flutter and seizure disorder. The patient had an EKG at 15:31 which showed NSR at 71 bpm. Physician ' s documentation indicated that the patient does not want anything done at this time and will see his prior cardiologist at another facility and that the patient understood the risks of leaving which includes continued chest pain, heart attack and death. However there is no documentation that staff requested the patient to sign a leaving AMA form as per facility ' s policy or that the patient refused to sign the form.

Similar findings noted in medical records for MR # 4 & MR # 5 with documentation that the patients left AMA but no evidence that the facility attempted to secure written refusal of further evaluation.

The Administrator was interviewed on 12/28/11 at approximately 4:30 PM. This staff reported that she went to the medical records department but there were no other papers in the records as were previously discussed.