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Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide five (P#6, P#10, P#11, P#14, P#15) patients out of 25 sampled records documentation related to informed refusal of treatment or sign a refusal document.

Findings Included:

One (P#6) patient record failed to have a completed leave against medical advice (AMA) form signed by the provider and witnessed by clinical staff.

Four (P#10, P#11, P#14, P#15) patient records failed to include a refusal for treatment document or documentation that attempts were made to have the patient review and sign a refusal document.

Cross Refer to A-2407.

Based on a review of policy and procedures, medical records, and interviews with staff, , it was determined that the facility failed to ensure that an appropriate and ongoing medical screening examination was conducted for five (P#6, P#10, P#11, P#14, P#15) patients out of 25 patients.

Specifically, the medical record reviews failed to reveal that the facility documented steps to discourage an individual from leaving the facility or document that attempts were made to locate the individual prior to setting a disposition of leaving the facility without being seen (LWBS), left after seeing the provider (LASP), and left against medical advice (AMA).

Findings Included:

Review of Emergency Department (ED) policies and procedures title "Completion of AMA Form' last reviewed 3/27/2023 revealed the purpose was to provide guidelines for the completion of the AMA form for patients who choose to leave Against Medical Advice (AMA).

Procedures: Whenever possible, an AMA form will be completed by the patient's EM or service physician on patients who elect to leave Against Medical Advice.
A. Only those patients who choose to leave after physician contact has been established will need to have an AMA form completed.
B. Patients who choose to leave prior to establishing physician contact are classified as "leaving without being seen".
C. The physician is responsible for completing all portions of the AMA form.
D. The nurse may witness the patient's signature on the AMA form.
E. If the patient refuses to sign the AMA form, the physician shall document that decision appropriately on the form and the nurse shall co-sign.
F. The EM attending, and the Charge Nurse shall be informed of all patients desiring to leave Against Medical Advice.
G. The AMA form will become a part of the patient's permanent medical record.

A review of the facility's policy titled, "ED: Management of patients who leave before triage or without being seen policy", policy #4251, last revised 3/16/23, revealed that the purpose of the policy was to establish guidelines for managing patients who wish to leave the ED prior to formal triage or leave without being seen by a physician.

Any patient indicating that they will be leaving before formal triage or prior to being seen by a physician and/or advanced practice provider (APP) will be encouraged to stay and complete their ED evaluation and treatment. If the patient has decision making capacity and still insists on leaving, a "Patient Refusal of care" form will be completed, this form will become part of the permanent medical record.

Patients leaving before triage and/or prior to being seen and evaluated will be brought to the attention of a physician and Charge Nurse.

A review of the facility's policy titled, "Nursing Documentation Policy", policy #3299, last revised 1/25/22, revealed that the purpose of the policy was to detail that the following nursing care documentation guidelines will be adhered to in order to assure care is provided to and documented for each patient based on a nursing assessment.

D. Emergency Department
14. ED Discharge/Left before completing visit/AMA process:
" Documentation of patient leaving AMA and patient leaving before visit completion can be completed by the nurse, EMT, or paramedic.
" Discharge order/instruction summary will be completed by the physician.

During an interview on 10/30/24 at 3:24 p.m., Emergency Department (ED) Nurse Manager (NM) FF said that she has been the ED NM for 10 years, and a Registered Nurse (RN) at the facility for 30 years.

ED NM FF said that when a patient is listed as leaving against medical advice (AMA), it means that the patient has already been evaluated by the provider and chooses to leave without treatment and has had the risks and benefits discussed by the provider. ED NM FF said that nursing staff are to have the patient sign the AMA form, but if they do not or if they walk out, then staff are to sign it and notate that the patient left and then get the form witnessed by another staff member.

ED NM FF said that when a patient is listed as left without being seen (LWBS), it means that the patient has not been seen by a provider and has chosen to leave the facility prior to this. ED NM FF said that sometimes patients will inform nursing staff they are choosing to LWBS and that staff are to encourage the patient to stay and have them sign a refusal of care form in the event they choose to still leave. ED NM FF said that the expectation is that nursing staff are to still make three attempted calls to the patient and document it in the electronic medical record (EMR).

ED NM FF said that when a patient is listed as left after seeing a provider (LASP), it means that the patient has seen the provider and agreed to the treatment plan but then decided to leave without telling staff or elope. ED NM FF said that an example of this is when patients are waiting for discharge paperwork and they choose to leave prior to receiving it but they have already gotten treatment and been stabilized. ED NM FF said that nursing staff are expected to make three attempted calls to locate the patient and document it in the EMR. ED NM FF said that depending on the situation of the patient, staff may have to get security involved and that would require an incident report.

A review of P#6's medical record revealed that P#6 left against medical advice (AMA). An AMA form was on file and signed by P#6, however it was not signed by a physician or witnessed by clinical staff.

A review of P#10's medical record revealed that P#10 left the facility without being seen (LWBS). Continued review of P#10's medical record failed to reveal any documented calls and attempts to locate P#10 when the facility realized that P#10 LWBS.

A review of P#11's medical record revealed that P#11 left the facility after seeing the provider (LASP). Continued review of P#11's medical record failed to reveal any documented calls and attempts to locate P#11 when the facility realized that P#11 LASP.

A review of P#14's medical record revealed that P#14 left the facility after seeing the provider (LASP). Continued review of P#14's medical record failed to reveal any documented calls and attempts to locate P#14 when the facility realized that P#14 LASP.

A review of P#15's medical record revealed that P#15 left the facility after seeing the provider (LASP). Continued review of P#15's medical record failed to reveal any documented calls and attempts to locate P#15 when the facility realized that P#15 LASP.