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Based on record review and interview, facility staff failed to ensure appropriate documentation was completed for 1 of 3 patients (Patient #6) who left against medical advice in a total sample of 20 emergency department medical records reviewed.

Findings include:

The facility failed to complete the appropriate documentation for 1 of 3 patients who left the Emergency Department against medical advice. See Tag A-2407.

Based on record review and interview, facility staff failed to ensure appropriate documentation was completed, per policy, for 1 of 3 patients (Patient #6) who left against medical advice in a total sample of 20 emergency department medical records reviewed.

Findings include:

On 10/23/19 at 12:35 PM, the facility policy #PC-161 titled, "Release from Responsibility (Against Medical Advice [AMA])," last revised 04/18 was reviewed and revealed, "Policy Statement: To guide hospital personnel as to when a 'Release from Responsibility' form is to be completed...Guidelines: A. The 'Release from Responsibility Form' will be completed in the following circumstances: 1. Leaving Against Medical Advice...B. If the patient refuses to sign the 'Release from Responsibility' form, BC-108, or leaves prior to signing, the RN (Registered Nurse) must complete the form documenting 'Signature refused' or 'Patient left before signature was obtained'. All staff witnesses to the incident should also sign the form."

Patient #6's electronic emergency room medical record was reviewed on 10/23/19 at 1:45 PM with Emergency Department (ED) Nurse Educator I who confirmed the following:

Patient #6 arrived to the emergency department on 7/25/19 at 2:17 PM via ambulance for "Heat Exhaustion."

At 2:20 PM, "ED Triage Notes" revealed, "Patient states [he/she] is a newly elected official and is waiting for the government to pick [him/her] up. [Patient #6] is currently living in a tent on property [he/she] claims [he/she] owns but [he/she] was contacted by the police today and [#6] asked to come to the hospital for heat exhaustion. [His/Her] symptom is fatigue. Patient has PTSD (post-traumatic stress disorder) and refuses to answer any other questions about [his/her] mental health because [he/she] states [he/she] is waiting to be briefed by the federal government."

At 2:23 PM, "ED Provider Notes" revealed, "...History: No chief complaint on file. HPI (History of Present Illness): ...Per nursing note, patient states [he/she] is a newly elected official and is waiting for the government to pick [him/her] up. [Patient #6] is currently living in a tent on property [he/she] claims [he/she] owns but [he/she] was contacted by the police today and [#6] asked to come to the hospital for heat exhaustion. [His/Her] symptom is fatigue. Patient has PTSD (post-traumatic stress disorder) and refuses to answer any other questions about [his/her] mental health because [he/she] states [he/she] is waiting to be briefed by the federal government. Patient states [he/she] now feels good. [#6] does endorse hearing voices 'daily' but denies self harm or suicidal content. [He/She] denies headache, chest pain, abd (abdominal) pain, vomiting. Patient states [he/she] does not take medication for [his/her] psoriasis...Differential Diagnosis: Psychiatric Disturbance...Medical Decision Making: 38 year old...presents to the emergency department c/o (complaining of) heat exhaustion. Vital signs stable, no elevated temperature, no tachycardia (fast heart rate), no dry mucous membranes. Patient has clear mental delusional disorder, but is able to make [his/her] own decisions and is alert. Refuses all care, and leaves before I can discuss options to ensure appropriate evaluation and walks out of the room."

At 2:53 PM, 36 minutes after arrival, "Patient Care Timeline" revealed, "Patient discharged."

At 2:54 PM, "ED Course" in the "ED Provider Notes" revealed, "Patient left AMA (against medical advice)."

At 2:55 PM, "Disposition" in the "ED Provider Notes" revealed, "AMA. There is no comment."

There was no further documentation found in the medical record regarding Patient #6's refusal of treatment or refusal to sign the "Release from Responsibility" form. There was no "Release from Responsibility" form found in Patient #6's medical record, per hospital policy.

During an interview on 10/23/19 at 1:47 PM, when asked about the documentation expectations when patients leave against medical advice and refuse to sign the form, ED Supervisor J stated, "The RN is still supposed to fill out the form and indicate the patient's refusal to sign. I see no form at all in this patient's (Patient #6) record."