HospitalInspections.org

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

1. The hospital's Risk Department reviewed all cases of Leaving Against Medical Advice (AMA) and elopements according to their hospital policy and procedure and that all patient safety concerns were then brought forth to the Quality Improvement Committee (QIC).

2. The hospital Risk Manager (RM) failed to address medical staff concerns regarding Emergency Department (ED) transfer and that all patient safety concerns were then brought forth to the QIC Committee.

These failures had the potential to adversely effect patient safety and care.

Findings:

1. During an interview with the RM on 2/4/14 at 2:45 PM, she stated, "No, I am not able to review all cases of elopement and AMA's for follow-up. If there is a patient safety concern it is brought to my attention and we do an incident report. The RM stated she did not have a log for AMA's and elopements, she further stated that it would be impossible to evaluate all cases because of the number of ED patients that were seen on a daily basis. When questioned regarding Patient 1's signing out AMA, she stated, "I did not receive a purple sheet (incident report) on that one. When asked if any ED transfer issues were brought to the attention of the QIC, she stated, "I have not had any issues with ED transfers reported to me, so I have not brought forth any issues to the QIC." She further stated she was not aware the hospital policy and procedure indicated all AMA's and elopements needed to be followed up.

The hospital policy and procedure titled, "Patient Elopement/AMA", dated , indicated in part, "4. Quality Management"; (a.) All cases of patient elopement or leaving AMA ( against medical advice) will be reported to Risk Management for evaluation and follow-up. (b) As required by Hospital policy, an unusual occurrence or incident report will be completed on all elopements and AMA's.

During an interview with Patient 1 on 1/30/14 at 10:25 AM, he stated, "A physician told me signing the AMA sheet was the quickest way to get out of this hospital and get help at another hospital. No one from Risk Management called me to ask what happened."

2. During an interview with ED Physician A on 1/31/2014 at 11:11 PM he stated, "I have spoken with our Medical Director regarding difficult transfers and it doesn't go anywhere. I reported this issue to risk management several times and they don't take it anywhere. I reported to risk management at least four or five times and we just don't get support or a response. I don't understand the process. That is just wrong."

During an interview with ED Physician B on 1/31/2014 at 2 PM, she stated, "I have reported ED transfer issues to risk, I have the nurses fill out the purple sheets and give them to risk management. I have received reports from other ED physicians regarding possible transfer violations and have reported these to the RM as well. She is then responsible for further information. I have never received any follow-up on these reports. Purple sheets or Incident reports are required on all elopements and AMA's. I'm not sure who does these."

During an interview with the Quality Director, she stated the hospital has not had a Quality Committee meeting since October and was not aware of any issues with ED patient transfers. She further stated the November, December and January meetings had been canceled and that the last meeting was mid-October.

The hospital policy and procedure titled Quality Improvement Plan, dated 11/20/13 indicates: 6. The Quality Improvement Committee provides a mechanism for employees and Medical Staff to suggest quality improvement activities and receive feedback ...the Quality Improvement Committee will be summarized and reported at least quarterly.