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Based on review of the medical record, review of the hospital's policies and procedures it was determined that the facility failed to enforce their policies to ensure compliance with the requirements under 489.24 in regard to being informed of the risks and benefits of not accepting treatment and attempts to obtain a signed informed consent for refusal of treatment. This was found in 2 (Patient 3 and 6) of 30 patients emergency department medical records reviewed who had presented to the hospital's emergency department for care during the month of April , 2011.


Findings include:

Please refer to A2407.

Based on review of the medical record, review of the hospital's policies and procedures it was determined that the facility failed to ensure patients received emergency medical treatment and failed to ensure the patient that refused medical examination and/or treatment was inform of the risks and benefits of not accepting treatment and the facility failed to attempt to obtain a signed informed consent for refusal of treatment. This was found in 2 (Patient 3 and 6) of 30 patients emergency department medical records reviewed who had presented to the hospital's emergency department for care during the month of April , 2011. The hospital had a total of 4,213 patients present to the Emergency Department during the month of April, 2011.

Findings include:

The medical record for Patient 3 was reviewed on 05/06/11. Patient 3 presented to the Emergency Department (ED) on 04/25/11 at 2:16 PM. Patient 3's arrival complaint was a request for detoxification from alcohol related to a heavy drinking problem for the past ten years which included a minimum of ten shots of hard liquor daily. Patient 3 also reported a history of seizures, anemia and high blood pressure.

Patient 3 was evaluated by the Triage Nurse (Staff E) and given an ESI (Emergency Severity Index-gives a level of 1 to 5 to establish the severity of a patients medical condition, with 1 being the most critical and 5 the least critical) level of 3.

At 2:25 PM the nursing documentation stated that Patient 3's family asked if the hospital provided inpatient detoxification and was informed the hospital does not provide these services. The patient's family, at that time, notified Staff E that the patient would be taken to another local hospital. Patient 3 left the hospital emergency department at 2:26 PM.

On 04/28/11 at 9:41 AM, a late entry was made in the Patient 3's emergency department medical record by Staff E. This entry further detailed the conversation between Staff E and the patient's family. Staff E encouraged the patient and his/her family to stay to see a doctor and notified them of available outpatient programs. Patient 3's family stated that he/she required an inpatient program and that they were going to leave and seek treatment elsewhere. There was no documentation in the medical record that the facility attempted to obtain a signed consent for refusal of treatment prior to Patient 3 leaving the facility.

The medical record for Patient 6 was reviewed on 05/06/11. Patient 6 presented to the ED on 04/30/11 at 5:21 PM with a complaint of feeling suicidal. Patient 6 reported a history of asthma, diabetes, high blood pressure, heart failure, depression and anxiety. The ED documentation stated at 5:30 PM, the nurse spoke with Patient 6 and that Patient 6 stated that they weren't going to hurt themselves but currently does not have any place to live and that if he/she felt suicidal he/she would return to the ED. Patient 6 left the ED at 5:30 PM.

There was no documentation in the medical record that Patient 6 was encouraged to stay for treatment, or that the risks of leaving without treament and did not attempt to obtain a signed consent for refusal of treatment prior to Patient 6 leaving the facility.

The hospital's policy and procedures for EMTALA was reviewed on 05/06/11. This policy #1.09.100 titled "EMTALA-Emergency Care and Transfer of Patients With Emergency Medical Conditions" was revised on 01/20/11 and stated the following:

1. Refusal to Consent to Treatment
The Hospital will meet its EMTALA responsibilities if the Hospital offers the individual further medical examination and treatment and informs the individual or responsible party of the risks and benefits of the examination and treatment, but the individual or responsible party does not give consent to the examination or treatment. The medical record must contain a description of the examination and/or treatment that was refused and the Hospital must take all reasonable steps to secure the individual's or responsible party's written informed refusal.

There was no documentation in the emergency department medical records Patient 3 and 6 that indicated the emergency department staff had obtained a signed refusal nor of attempts by the emergency department staff to obtain a signed refusal of medical examination and treatment which is required by the hospital's emergency department policy.

This citation substantiates complaint number OH00060693.