HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that patient medical records must contain the patient's progress and response services, by failing to ensure patients leaving the facility Against Medical Advice (AMA) completed a waiver documenting this decision.

Findings included:

Facility Policy entitled, "Patient Transfer (EMTALA)" stated in part,
"Patient Refusal
If a Patient refuses to consent to further examination, treatment, and/or Transfer, medical center staff should take reasonable steps to secure the written informed refusal of such examination, treatment, and/or transfer from the Patient or from a person acting on a Patient's behalf refusing a related examination and/or treatment.
o The Patient must receive an explanation of the risks .and benefits of the examination, treatment, and/or Transfer (including not effecting the Transfer).
o The medical record must contain a description of the examination, treatment, and/or Transfer that was refused by or on behalf of the Patient.
o The documents reflecting such refusals should indicate that the Patient has been informed of the risks and benefits of examination, treatment, and/or Transfer; should be signed, if possible, by the Patient or person acting on the Patient's behalf, dated, and witnessed ·by the attending physician or a medical center staff; and placed in the Patient's record."

Facility policy entitled, "Patient Leaving (Leaving the Floor/Against Medical Advice/ Elopement)" stated in part,
"Against Medical Advice ("AMA") - An unauthorized departure in which the patient:
1. Reviews the consequences/risks of leaving/removing the patient AMA with the patient's physician (or advance practice professional when appropriate); or,
2. Refuses to wait to review the consequences/risks with the patient's physician (or advance practice professional when appropriate) ...

Against Medical Advice ("AMA")
1. The physician (or advance practice professional when appropriate) should discuss with the patient or third party the reason for wanting to leave/remove the patient from the facility with the patient. The physician may inform the patient or third party of the potential adverse clinical consequences/risks of leaving/removing the patient from the BSWH facility AMA. If the patient or third party refuses to review or wait to review the consequences/risks of leaving/removing the patient AMA, please follow these AMA procedures below...

2. The patient or third party should be asked to sign the Leaving Against Medical Advice Waiver and Release form. The form should be witnessed and placed/scanned in the patient's medical record.
a. If the patient or third party does not sign the Leaving Against Medical Advice Waiver and Release form for any reason (e.g., refused to sign, left the facility before the form was presented), staff may follow the directions on the bottom of the form for documenting why the form was not signed, and the director, nurse manager, or administrative supervisor maybe notified. The form should be witnessed by two (2) witnesses and placed in the patient's medical record."

Review of medical records revealed 3 of 11 patients (#1, 4, and 6) did not complete a Leaving Against Medical Advice Waiver and Release form or have staff witness and document on the form why it was not completed.
* Patient #1 left the facilityAMA on 07/12/23, there was no Leaving Against Medical Advice Waiver and Release form in their medical record.
* Patient #4 left the facility AMA on 08/08/23, there was no Leaving Against Medical Advice Waiver and Release form in their medical record.
* Patient #6 left the facility AMA on 08/14/23, there was no Leaving Against Medical Advice Waiver and Release form in their medical record.

Due to the Leaving Against Medical Advice Waiver and Release form not being completed or staff witness and document on the form why it was not completed, it cannot be established the above patients were notified of the risks associated with leaving AMA. The Leaving Against Medical Advice Waiver and Release form also provides supporting evident that the patient themselves were requesting to leave the facility. The Leaving Against Medical Advice Waiver and Release form also effectively documents the patient's response to treatment in the medical record, that they requested and decided to leave the faciliyt AMA rather than continue receiving treatment.

The above findings were verfied on 09/05/23 with staff members #1 and 2.

Based on observations, review of records, and interview the facility failed to comply with §489.24, as evidence by, failing to provide an appropriate medical screening examination, to determine whether or not an emergency medical condition exists, as evidence by failing to assess a patient that had left the facility Against Medical Advice and collapsed on facility property, a facility security guard after witnessing the patient's collapse, called for an ambulance that took the patient to different facility for evaluation and treatment.

Findings included:

Please cross refer to A2406.

Based on a review of records, observation, and interview, the facility failed to provide an appropriate medical screening examination, to determine whether or not an emergency medical condition exists, as evidence by failing to assess a patient that had left the facility Against Medical Advice and collapsed on facility property, a facility security guard after witnessing the patient's collapse, called for an ambulance that took the patient to different facility for evaluation and treatment.

Findings included:

Facility Policy entitled, "Patient Transfer (EMTALA)" stated in part,
"Patient-is an individual admitted to the medical center or seeking medical treatment who:
1. may or may not be under the immediate supervision of a personal attending physician;
2. has one or more undiagnosed or diagnosed medical conditions; and
3. within reasonable medical probability, requires immediate or continuing medical center services and medical care ...

Patient Evaluation

Medical Screening
When a Patient comes to a BSWH medical center's dedicated emergency department requesting examination or treatment for emergency care, the Patient must be evaluated with a medical screening exam by qualified medical personnel ("QMP"), as authorized by the medical center's Governing Body. Following examination and assessment of the patient by a Registered Nurse ("RN") QMP, the RN communicates with the physician to apprise him/her of the findings. Based on this assessment, the physician determines disposition and gives appropriate orders.
o In absence of an actual request, if a. "prudent layperson" would believe the individual needs an examination or treatment for emergency care the person must be evaluated with a medical screening exam.
o If the Patient comes to a location other than the dedicated emergency department or off the main campus, staff at that location should follow the protocols established for that location which may include contacting emergency services for all Patients in need of emergency care ..."

One out of eleven patients (#1, 3-12) who left the facility Emergency Department Against Medical Advice (AMA) between July and August 2023 suffer what per facility policy, " a 'prudent layperson' would believe the individual needs an examination or treatment for emergency care the person must be evaluated with a medical screening exam."This one patient did not receive a Medical Screening Exam and was instead sent to another facility via ambulance.

Review of the medical record or Patient # 1 reveled the following:
Patient #1 initially present at this facility on 07/12/23 at 1809 due to, "Pt found in front of hospital on ground, blood dripping, from mouth. Pt initially not verbally responding, appeared disoriented."
Patient #1 was medical screened by a physician on 07/12/23 at 1812.
Patient #1 subsequently left the facility Against medical Advice (AMA) per documentation on 07/12/23 at approximately 2000. This patient did not complete a Leaving Against Medical Advice Waiver and Release form or have one completed by witnessed indicating their refusal to complete the waiver, per facility policy.

A Security End of Shift Report on 07/12/23 completed by staff member #3 stated in part, "At approximately 7:20 pm, ED RN [name] asked me [Staff member #3] to standby as they anticipated issues with the patient in ED room 5. The patient left the ED AMA after refusing offered treatment. I escorted him to the door and observed him leaving premises. I saw him collapse near Staggerbrush and Roadrunner at approximately 7:45 pm. I responded to his location and confirmed he was minimally responsive with a strong pulse and respirations. I contacted
[city] Dispatch to request an ambulance from AEMS. AEMS Unit 11 arrived and transported patient to [different facility] for further care." This note idenitfied it was pertaining to Patient #1.

In an interview on 09/05/23 with the Security Guard, Staff member #3 they verfied that the above incident involving patient #1 occurred on facility property, "Still on our property by about 6 feet maybe, right on the corner of our driveway and where Staggerbush meets, a little bit short of Roadrunner, he was actually laying on our driveway before it contacts Staggerbush." Staff member #3 also verfied witnessing Patient #1 collapse on the facility property resulting in Staff member calling for an ambulance. Staff member #3 stated after deciding to leave AMA, "I took him [Patient#1] to our ambulance entrance, it's shorter walk. I told him, 'I'm gonna keep an eye on you'. He headed out the road toward the back I saw him collapse which wasn't too surprising considering the condition he was in. I went over that's when I called dispatch ... I called dispatch that's our protocol and had them have County EMS send an ambulance to that location."

Per an EMS Incident Detail Report sheet, EMS responded to an incident location of "Staggerbrush Rd / Roadrunner Ln" on 07/12/23.
According to the Incident Detail Report:
* On 07/12/2023 at 19:47:29, "40-year-old, Male, Not Conscious, Breathing status unknown. Problem Description: POST SEIZURE Chief Complaint: 12, CC Text: Convulsions/Seizures."
* On 07/12/2023 19:48:10, "CALL CAME IN FROM BSW SECURITY DISPATCH".

Patient #1 was then transported to different facility by EMS to be assessed and treated.

Tour of the facility and campus area on 09/05/23 revealed the following: Outside the entrance to the Emergency Department it was observed that Staggerbush Road runs parallel to the building into the cross street of Roadrunner Lane caddy corner to the left of the building [ED Entrance]. The visual observation the 2 crossroads in context to the facility was verified by Staff members #1, 2, and 4 who accompanied the surveyor on the tour.

Based on the above findings, Patient #1, was still on facility property when they collapsed and appeared to be suffering from a possible emergency medical condition, as witnessed by the facility security guard. Due to still being on facility property and appearing to have an emergency medical condition, this patient should have received another appropriate medical screening examination to determine of a medical condition existed. Instead this patient was sent to a different facility to receive a medical screening examination.