HospitalInspections.org

Based on interview and record review, the hospital staff in its emergency department (ED) instructed two of 44 sampled patients (43 and 44) to sign Against Medical Advice (AMA) and sent them to seek medical treatment at another hospital without providing needed medical treatment onsite to stabilize their emergent medical condition. This action had placed these patients' health and safety at risk.

Findings:

1. On 1/29/14, Patient 43's clinical record was reviewed. Patient 43 was chosen because the ED tracking log indicated that his discharge diagnoses was renal (kidney) stone and signed AMA. Patient 43 was a 43-year-old Hispanic uninsured man who went to the hospital of complaint of bilateral flank pain for two days. The patient arrived at the hospital's ED on 12/10/12, at 7:34 AM. The triage and initial assessment completed at 7:37 AM indicated his intensity of pain was 10 (A scale of 1-10, 10 as the worst) located to his left flank. Patient 43's white blood cell count was 11.7 (normal range is 4.5 to 10) and had had multiple urinary tract infections in the past. The final "ED Physician Notes," dated 12/10/12, at 10:22 PM, read: "He (Patient 43) has normal renal (kidney) function and had a CAT (Computerized Axial Tomography, a diagnostic test uses X-ray and computer to generate images of internal organs or structure of body) that showed severe chronic hydronephrosis (water in the kidney, usually caused by obstruction of urine flow from the kidney) with very minimal stranding." The discharge diagnoses were hydronephrosis and obstructive uropathy (a structural or functional hindrance of normal urine flow). ED staff tried to transfer the patient to the county hospital but the county hospital refused the transfer. The patient was given discharge instructions on "Kidney Stone [with/Colic (sudden an violent pain)] and instructed to go to the county hospital that had denied the transfer for treatment in 1-2 days. The plan for the patient's disposition, on the final notes, was "Discharged: To home, AMA."

On 1/30/14, at 8:25 AM, Patient 43 was interviewed via a telephone call. Patient 43 spoke Spanish only. His son got on the telephone and translated during the interview process. Patient 43' son stated, "It hurt really bad." When asked if his father refused to be transferred, he, after checking with his father, stated, "They don't want him there; they told him to go home." At this time, it was asked if his father could identify the staff who instructed him to sign the AMA form, the son replied, "(It) was the physician there told him to leave."

2. On 1/29/14, Patient 44's clinical record was reviewed. Patient 44's record was chosen because he came to the hospital ED for treatment due to urethral pain. Patient 44 was a 38-year-old uninsured male who lived out of State and worked locally for a temporary job. He presented to the ED on 8/5/13, at 5:36 PM, with complaint of painful urination. On the initial assessment, it read, "Patient describes the pain as burning and when he is not trying to pee it is a 2/10 (pain scale of 1-10) and when he tries to pee or has the urgency to pee it increases to a 7/10." An X-ray of pelvis showed the patient had a stone in the tip of the penis and an ultrasound (Ultrasound produces sound waves that are beamed into the body causing return echoes that are recorded to "visualize" structures beneath the skin) revealed he had a distended (enlarged) bladder. A urinary catheter and a needle were used to attempt to drain urine and remove the stone but were both unsuccessful. The staff at the ED tried to transfer the patient to other hospitals for consultation but was also refused. The final "ED Physician Notes," entered on 8/6/13, at 1:58 PM, read, "Final Diagnosis: the patient is urinating around the distal stone and he does not have bladder distention or acute urinary retention or acutely complete obstructing stone clinically without fever or chills;" and "Disposition: patient ended up signing out against medical advice with the appropriate form understood and signed on the chart." Patient 44 left the hospital on 8/6/13, at 1:27 AM and arrived at the county hospital at 2:21 AM. His stone was removed at the county hospital.

On 1/30/14, at 10:25 AM, during a telephone interview, Patient 44 stated he went to the hospital emergency department because he had a stone and was hurting and could not urinate. The patient was asked to describe the intensity of the pain, he replied, "It was 8-9." Patient 44 was asked what was the reason by leaving the ED against medical advice; he stated a male staff told him to sign AMA in order to get to the other hospital for treatment quicker. He said, "It was the quickest way to get out of there, otherwise, I have to wait for a long time. They gave me a map of the other hospital." He further stated he wanted to leave so quickly because "I was hurting so bad, I would do anything." Another subsequent interview was conducted on 2/3/14, at 10:33 AM, Patient 44 described at the time of leaving the hospital he was hurting pretty good. "I had to pee really, really bad. They tried a catheter and I still couldn't pee because of the stone."

On 1/30/14, at 2 PM, during an interview, the Director of the ED was informed of the above two findings. He was not aware that these two patients were told to sign an AMA form to leave the hospital and seek medical treatment at another facility. He stated he was not aware that any physician would coerce patients to sign AMA and would not consider severe pain is stable. "It is a violation of EMTALA (Emergency Medical Treatment and Labor Act, a set of regulations prohibits hospital with emergency departments from refusing to examine or treat individuals with an emergency medial condition). We follow EMTALA policies and procedures."

On 1/31/14, at 2:08 PM, during an interview with the Medical Director of the ED, who was on duty at the time when Patient 43 was being discharged, she stated, "I was aware of his AMA; but he did not want to be transferred. He was not hurting." She explained further, "Our standard would be to have our patients transferred per protocol. You just can't just send them home with pain. It has been very difficult to transfer patients to (Name of two local hospitals)." Asked if she would coerce patients to sign AMA and go to another hospital, she replied, "No, that would be an EMTALA violation. "

On 1/31/14, at 11:11 AM, an ED physician (Physician A) was interviewed. Physician A was the discharging physician for Patient 44. He was asked if Patient 44 was stable enough to be discharged. He stated, "It depends on what we see and the patient's condition." He believed the patient was in stable condition at the time of discharge. He was questioned if he had encouraged the patient to sign AMA in order to seek care at another facility; he replied, "No, we don't. We, attending MDs (medical doctors), arrange transfers. If unable to get a patient to transfer, we will get the patient to urology clinic to see patient through ED." Physician A denied he had told the patient to sign AMA. He stated he had tried to transfer the patient to other facilities that offered urologist on-call but they refused to take him.

During an interview on 2/3/14, at 5:40 PM, on having patients to sign AMA, an anonymous staff stated, "I had patients to sign AMA is to protect myself and the hospital from violating EMTALA (regulations)." Asked if this was a common practice in the emergency department, he replied, "Yes, there are nothing we could do to help patients."

The Interpretive Guidelines for Section 489.24(d)(1)(ii) read, "When a hospital has exhausted all of its capabilities in attempting to resolve the EMC (emergency medical condition), it must effect an appropriate transfer of the individual." The hospital failed to meet the requirement when its ED staff had these two patients (43 and 44) leave the hospital AMA and seek treatment at a county owned hospital.