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Based on review of policy and procedures, incident logs, medical records, and interviews with staff it was determined that the facility failed to ensure that two (P#1 and P#3) of twenty sampled patients were informed of the risks and benefits of leaving the facility against medical advice (AMA).

Cross refer to A-2407 as it relates to the facility's failure to ensure that patients leaving AMA are informed of the risks and benefits of doing so for all patients leaving AMA per the facility's policy.

Based on a review of policy and procedures, an incident log, medical records, and staff interviews it was determined that the facility failed to ensure the risks and benefits of leaving AMA were explained and documented for four (P#1, P#3, P#6, P#14) of twenty sampled patients. P#1, P#3, P#6, and P#14's medical records failed to include documentation that the risks and benefits of leaving AMA were explained to the patient or patient's representative.

Findings Included:

A review of the facility's policy titled "Against Medical Advice, Elopement, and Left Without Treatment (All)", policy number 12259691, last approved 10/22, revealed that when a patient decided to leave any department of the hospital without the physician's consent or knowledge, hospital staff should attempt to provide for the care, welfare, safety, and security of the patient without infringing on the patient's rights.

Definitions:
"Left Without Treatment (LWOT): All persons who presented at a patient access area but left before being seen by a doctor.

"Emergency Room- Patients who leave before treatment was complete: A patient classification that encompasses those individuals leaving the emergency department (ED) after the medical screening exam (MSE) but before the provider documented the treatment was complete.

"Against Medical Advice (AMA): All patients who had been seen by a doctor in a patient care area left the hospital against medical advice.

Procedure-
AMA
1. Verbalize understanding of the risk related to refusing treatment.
AMA Recommended Actions: The Registered Nurse (RN) would:
1. Notify the attending as soon as possible.
2. Notify the Unit Director and/or House Supervisor.
3. Provide the patient and/or legal guardian with information on the risk of leaving the hospital AMA and the benefits of staying. Make the patient aware of his/her condition and the danger he/she is assuming. Instruct the patient/legal guardian that the hospital and physician were no longer legally responsible once he/she left.
4. If possible, obtain the patient's signature on the AMA form and attach the form to the medical record (MR). If a patient refuses to sign the form and leaves the hospital, the date, time, and patient's refusal to sign the form should be documented in the patient's MR and on the AMA.
5. Complete a hospital Occurrence Report.
6. Document in nurses' notes the reason the patient the patient/legal guardian gives for leaving and the instructions they were given. The condition of the patient/legal guardian should be noted and his/her objective mental and physical status.

Post-Elopement actions of the non-behavioral health and/or patient not at risk of harming themselves or others: The RN should-
1. Search the hospital property: Note- If staff contacts the patient, they should attempt to encourage the patient to stay and receive treatment.
2. Notify the attending physician as soon as possible.
3. Notify co-workers and security for assistance.
4. Notify the Unit Director and/or House Supervisor.
5. Notify the patient's authorized contact to ensure the patient is safe.
6. Document that the patient eloped in the patient's medical chart and what subsequent actions were taken, including who was notified.
7. Complete hospital Occurrence Report.
8. Once the search for the patient has been completed and they have not been located on the campus, the patient would then be discharged in the electronic MR.

If the patient did not meet the criteria for AMA, notify the Police Department immediately and verbally notify the Director of Risk Management.

LWOT:
1. The patient was classified as LWOT if the patient meets the following criteria:
a. Has not been evaluated by a provider.
b. Document in the record that the patient LWOT, including the time it was discovered.
c. If the reason for the LWOT was known or could be obtained, indicate this on the Emergency record triage record.
d. If staff were aware of the patient leaving the ED prior to an MSE, discuss the risks and benefits and attempt to get the patient to stay at the hospital and document in the MR.

A review of the facility's policy titled "Occurrence Reports", policy number 13176973, last approved 3/2023, revealed that an occurrence was a hospital-related event not consistent with the usual or desired operation of the hospital or the care of the patient. The responsibility was for all staff. The Safety Incident Management (SIM) also known as RL Solutions, was an electronic occurrence reporting system and was accessible through the hospital intranet.
Occurrence Reports were as follows:
" Anything that occurred to a patient or visitor that was unexpected and caused harm or had the potential to cause harm.
" Anything consistent with routine patient care
" Anything clinical or any process you identified as something to avoid in the future.
" Good Catch events

Reportable events included AMA and elopements.
Submitting Occurrence Reports:
1. SIM reports could be submitted.
2. Reports should include the event date, patient information, and a detailed summary of the event. Enough information should be provided for the event to be investigated including patient information, specific department/location of the event, and potential witnesses to the event.
3. Only factual information should be reported.
4. Risk Management should be contacted immediately for all occurrences associated with injury, and for any Sentinel Event.

A review of the facility's incident log dated 1/1/24 through 4/9/24 failed to reveal that an incident was completed on P#1, P#3, P#6, and P#14, after all were documented as leaving the ED AMA.

A review of P#1's ED medical record revealed that P#1 walked into the ED on 3/7/24 at 10:03 p.m. with a chief complaint of left-sided chest pain and lightheadedness. Continued review revealed that a medical examination screening (MSE) was conducted with patient (P) #1 on 3/7/24 at 11:24 p.m. P#1 had a history of congested heart failure (weakened heart condition, coronary artery disease (narrowing or blockage of the coronary arteries), and hypertension (pressure in your blood vessels is too high).

A review of "Orders", dated 3/7/24, revealed that P#1 was ordered an electrocardiogram (EKG) 12 lead (heart's electrical activity recorded from electrodes on the body surface) at 10:07 p.m., 10:51 p.m., and 11:51 p.m. In addition, at 11:52 p.m. orders were placed for a chest x-ray and blood work. The results of the blood work were posted to P#1's medical record on 3/8/24 at 5:22 a.m.

A review of "Admit-Discharge-Transfer Form", dated 3/8/24 at 1:57 a.m., revealed that P#1 told registration they were leaving at 1:36 a.m. Further review revealed that P#1's ED disposition was documented as left against medical advice (AMA). In addition, the AMA form was not provided, reviewed, or signed by P#1. P#1 was discharged at 1:57 a.m.

A medical record review of P#3 revealed that P#3 presented to the facility's ED on 3/6/24 at 4:28 p.m. with a complaint of chest pain, severe heavy bleeding, and passing clots. An MSE was completed at 5:27 p.m.
Continued review revealed that the "Admit-Discharge-Transfer Form" was completed at 7:54 p.m. by Registered Nurse (RN) EE.
The following was documented:
ED disposition- Left AMA
ED Reason for leaving- Unknown.
Refusal of Treatment Form- Form not read; patient left.
ED Risk of Leaving AMA- No

Further review of the medical record revealed that P#3's discharge disposition was changed to AMA on 3/6/24 at 8:54 p.m. Continued review failed to reveal an AMA form or physician notification.

A review of the medical record for P#6 revealed that P#6 arrived at the facility's ED on 3/1/24 at 10:10 p.m. with a complaint of back pain. Continued review revealed that P#6 had a disposition of left AMA on 3/2/24 at 4:39 a.m. The medical record failed to reveal an AMA form. Continued review failed to reveal documentation that risks and benefits of leaving AMA was discussed with P#6.

A review of P#14's medical record revealed that P#14 arrived at the facility's ED on 1/3/24 at 8:27 p.m. from an urgent care center for further treatment. Continued review revealed that P#14 had a disposition set as left prior to triage on 1/3/24 at 9:09 p.m. The MR did not reveal documentation of any listed times P#14 was called by the triage nurse.

During an interview on 3/10/24 at 12:50 p.m. with Director of Patient Safety (DPS) II in a conference room, DPS II stated that these surveyors would not be able to find occurrence reports for any patients that left the facility's ED AMA in the incident log because she looked. She added that the only unit that would file an occurrence report for patients who leave AMA would be a unit that cares for patients who have been admitted and the patient leaves AMA.

A follow-up interview was conducted on 4/10/24 at 1:00 p.m. with Director of Emergency Services (DES) FF in the boardroom. DES FF stated she had been in the position for two years. DES FF explained that if a patient left after an MSE was completed, the disposition would be left AMA. She explained that if a patient wanted to leave the ED prior to discharge, she expected staff to try and figure out why the patient wanted to leave. She also expected staff to contact the charge nurse and the patient's provider. The expectation was that the provider would speak to the patient at the bedside about the risks and benefits of leaving. DES FF said that the charge nurse was responsible for ensuring that the AMA form was signed and that the risks and benefits specific to the patient were listed. She explained that the nurse and provider should sign the AMA form. DES FF said an occurrence report was not filed for patients who left AMA. She explained that she was unaware that facility policy required that occurrence reports be filed for patients who left AMA. She said that the charge nurse was responsible for changing the depositions for discharge, including AMA, elopement, and leaving without treatment (LWOT). DES FF explained that if a patient left before being triaged or receiving an MSE, the disposition would be LWOT. DES FF said that she expected staff to try to call out for a patient thrice, fifteen minutes apart, before changing a patient's disposition to LWOT. Staff should be documenting these actions in the patient's medical record. DES FF also explained that elopement dispositions were for behavioral health patients who had left prior to discharge. She said that if a patient had a 1013 (legal document to hold a patient involuntarily for mental health treatment) and left the ED, local law enforcement would be notified. If a behavioral health patient did not have a 1013 and left the ED prior to discharge, staff would be expected to call the patient or legal guardian to check on the patient. In addition, she said that a copy of a 1013 should always be in the patient's medical record. She explained that documents (i.e., AMA, 1013) were not scanned into the medical records in the ED. The documents were scanned in the medical records by the facility's Health Information Management (HMI) department. DES FF explained that she sent out a monthly update flyer about four weeks ago to educate staff about AMAs. Prior to the education, the patient's nurse was responsible for entering the discharge dispositions into the medical record. She also explained that staff were unable to view if the provider had started the MSE in the medical record. The MSE was not available in the MR until the provider signed off, usually 24 hours.

During an interview on 4/10/24 at 1:32 p.m. in the conference room, Registration Clerk (RC) GG said that she has been employed at the facility for seven years. RC GG said that when patients walk into the ED, they are greeted by an RC who performs a mini registration that includes taking the patient's name, inquiring if the patient was seeking treatment and what was their reasoning for seeking treatment. RC GG said that if the patient reports shortness of breath (SOB), chest pain, bleeding, or anything that may require performing an electrocardiogram (EKG) (a test to record the electrical signals of the heart) then they call for a triage nurse to immediately see the patient. RC GG said that all other patients are logged in and waiting for a triage nurse to call the patient for triage. RC GG said that for anything that may require clinical care or if the patient is in visual distress, the RC must alert the triage nurse via a walkie-talkie.

RC GG said that the RCs have a discharge desk, and once patients are discharged, they visit the desk to discuss payment. RC GG said that if a patient decides to leave prior to being seen by a provider, the RC requests the patient to come to the registration desk to inform them and the RC will attempt to get the triage nurse to assess the patient. RC GG said that sometimes patients leave the waiting room, and they simply walk out prior to being seen by a provider and the RC should notify the Charge nurse. RC GG said that registration does not occur in the back, so the RC does not play a part in patients who leave against medical advice (AMA) unless the patient stops by the front registration desk or the discharge desk. RC GG said that if the patient comes to either desk, they will inform the Charge nurse and the provider so that they may talk with the patient.

An interview was conducted with Nurse Practitioner (NP CC) on 4/10/24 at 3:05 p.m. in the conference room. NP CC stated that he recalled P#2 because she presented to the ED from another facility stating that she had sepsis and needed a bolus (a single, large dose of medicine). P#2 was seen in the ED's Rapid Care Unit (RCU). NP CC recalled reviewing P#2's lab work from a previous visit. NP CC spoke with the patient and advised her that he did not see any indication of sepsis. NP CC stated that he left to review the previous chart and write new orders and when he returned, he was advised by the nurse that P#2 had walked out and left. NP CC stated that he does not list patients as AMA until he can speak with them first and explain the risks and benefits of leaving AMA. NP CC added that if a patient leaves before he can speak with them, he would document them as LWOT or elopement. NP CC said he would never document a patient diagnosis as elopement or document a discharge disposition as AMA in the same ED visit. He further added that it was his expectation of staff to notify him when a patient says they want to leave without treatment so he can speak with the patient prior to discharge. NP CC stated that patients who want to leave without treatment are asked to sign an AMA form which is additionally signed by the provider prior to discharge.