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Based on review of medical records, review of policy and procedures and staff interview it was determined the facility failed to inform the patient of the risks and benefits of leaving prior to examination and treatment for one (Patient #1) of twenty patients sampled.

Findings included:

Review of the facility policy, "Emergency Department - Left Without Treatment (LWOT)", #BC-ED-122, stated Procedure: leaves without treatment - patient notifies staff of intent, 1(a) the nurse informs the patient of the risks of leaving prior to receiving the examination and treatment; (2) if the patient remains insistent on leaving, the nurse will (a) explain leaving without a medical screening and (b) request signature on the discharge AMA/LWOT form; (3) document the circumstances surrounding the patient's decision to leave without treatment and the time the patient leaves the emergency department.

Review of the medical record for patient #1 revealed the patient presented to the facility ED (Emergency Department) on 12/02/2019 at 8:47 pm. Documentation revealed the patient was a walk-in, attended by a friend and the stated complaint was being sick. Nursing documentation revealed the patient did not sign the consent to treat due to the patient's friend stating the patient was "too sick" to sign. The patient refused to speak or answer any questions. Documentation revealed the patient's friend became loud and verbally aggressive and the patient stood up from the chair and left the facility with the friend.

Review of the medical record revealed no evidence the nurse informed the patient of the risks of leaving prior to receiving an examination and treatment. There was no evidence the nurse requested signature on the discharge LWOT form.

An interview and review of the medical record was conducted with the Manager of Clinical Professional Practice West Region on 6/9/2020 at 3:00 pm at which time the above findings were confirmed.