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Based on medical chart review, policy review, and interviews the facility failed to ensure that patients leaving Against Medical Advice (AMA) received appropriate risk and benefits from the physician and failed to document that the provider was aware of the AMA in 2 (#3 and #5) of 3 (#3, #5 and #6) medical charts.

Findings:

Patient #5
A review of patient # 5's medical chart revealed she was seen in the Emergency Room (ER) on 12/17/24 at 17:07 by staff # 11 RN FNP, as the provider for abdominal pain. A review of the nurse's note dated 12/17/24 at 19:45 stated, "Discharge Vital Signs Exam Date/Time 12/17/2024 19:45.

Disposition Left AMA Capacity for AMA Discharge Against Medical Advice Assessment Time 12/17/2024 19:45, Cognition Oriented to Person Place, and Time, Gives Appropriate Answers, Gives Rational Explanation of Refusal of Care, Speaks Coherently with no Slurring, No Signs of Psychosis or Hallucinations, No Delusional or Tangential Thinking, No Suicidal or Homicidal Ideation; Issues Reviewed & Discussed w/ Patient, Care Being Refused Medical Treatments, Comprehension Aware of Suspected Diagnosis, Acknowledges Understanding of Reasons for Recommendations; Risks of Refusing Care Death Acknowledged, Quadriplegia Acknowledged, Paraplegia Acknowledged, Permanent Mental Impairment Acknowledged, Loss of Limb Acknowledged, Loss of Sexual Function Acknowledged, Loss of Current Lifestyle Acknowledged; AMA Details AMA Form Signed, The patient was made aware of education available electronically Yes, IV Access Removed Yes, Departure Time 12/17/2024 19:45."

There was no documentation from the RN if the provider was notified, why the patient was leaving AMA, or if the provider provided the risk and benefits. The RN documented on the AMA form that the risks were "Loss of life, loss of limb, and loss of lifestyle." There were no benefits listed for staying in the ER to finish treatment. These risks were not relatable to the patient's complaint of abdominal pain. There was no documentation if the patient was still in pain. There was no physician/provider signature on the AMA form.

A review of the provider note dated 12/17/24 at 21:21 stated, "Disposition Left AMA." There was no reason the patient left, and no information that the provider gave the patient any risks or benefits.

Patient #3
A review of patient #6's chart revealed she came into the ER on 12/21/24 at 19:59 via ambulance after she had a seizure. The patient was seen by staff # 12 RN FNP as the provider. A review of the chart revealed the RN documented on 12/22/2024 at 01:40 "Patient states that she doesn't want to be admitted that she feels fine and doesn't see why she needs to stay. The patient also stated that she had not taken her seizure medications in the last few days. Educated patient on the importance of taking her medications as prescribed to prevent future seizures. _____Staff #13 (physician) notified that patient is wishing to leave and not be admitted. Physician spoke with patient about being admitted but continues to refuse to be admitted. Again ____Staff #13 (physician) was notified and states that she will need to leave AMA. Patient informed and is agreeable to sign AMA form." A review of the AMA form revealed the patient signed the form but there was no signature that risk and benefits were given by the provider.
A review of the provider notes dated 12/22/24 at 0132 stated the patient was being admitted to the hospital. There was no documentation that the provider was even aware that the patient was leaving AMA.

A review of patient #3's AMA form stated the risks were "Death, worsening of symptoms, permanent mental impairment, loss of current lifestyle." There were no benefits listed. There was no physician's signature.

A review of the policy and procedure ACCEPTANCE OR REFUSAL OF MEDICAL SURGICAL TREATMENT - AMA stated, "Leaving Against Medical Advice (AMA):
POLICY:
It is the policy of Nacogdoches Memorial Hospital to comply with Texas law regarding informed consent and the patient's right to accept or refuse medical or surgical treatment ...
When a patient verbalizes the intention of leaving AMA, the nurse should:
1 . Notify the physician and Director/Department Head or House Supervisor.
2. Attempt to form an alliance with patient and family.
AMA Form:
The AMA form is a self-carbon duplicate form.
Place label in the right lower corner.
List in detail any risks which are associated with the patient leaving AMA.
List in detail any appropriate post hospital instructions (i.e., wound care, follow up physician appointments, etc.).
Explain the risks and follow up instructions to the patient. Explain to him that he may return if he changes his mind or if his symptoms worsen.
Ask the patient to date, time and sign the AMA form. If the patient refuses to sign, write "patient refuses to sign" in patient signature space. Ask the nearest relative, if available, to sign.
Have a staff member witness the signature.
Give the copy of the AMA form to the patient or family member. Place the original in the patient's chart.
AMA Documentation:
1 . Complete the AMA form as listed above.
2. Document the following in the patient's chart:
a. Vital signs.
b. General appearance.
c. What you told the patient regarding the possible consequences of signing out AMA.
d. Evidence that the patient understood the risks.
e. The patient's stated reason for signing out AMA.
f. Any unusual circumstances surrounding the signing of the form.
g. Names of witnesses.
h. Time and mode of discharge.
To courtesy, respect, dignity, and timely, responsive attention to his or her needs. To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment."

The policy and procedure designate the nurse to give the patient the risk and benefits and not the physician/provider. The physician must determine the patient's capacity to consent and give the risks and benefits according to the patient's medical issues. The facility failed to ensure that the physician/provider was notified of the patient's request for AMA and documented the appropriate risks and benefits.