HospitalInspections.org

Based on review of medical records,policies and procedures, ambulance reports, Police Department reports, and interviews the facility failed to ensure that the medical record contained documentation that individuals were informed of the risks and benefits to individuals who do not consent to further treatment for 1 (#19) of 20 sampled patients.
Refer to findings in Tag A-2407.

Based on review of medical records,policies and procedures, ambulance reports, Police Department reports, and interviews the facility failed to ensure that the medical record contained documentation that individuals were informed of the risks and benefits to individuals who do not consent to further treatment for 1 (#19) of 20 sampled patients.


Findings Include:


Ambulance Trip Report
Review of the ambulance Patient Care Report for Patient #19 revealed: A call was received on 6/19/2016 at 5:33 PM and an ambulance unit arrived at Patient #19's residence at 5:47 PM. Patient #19 was found standing and complained of high blood sugar. Patient #19 did not appear in distress, and no alteration in mental status was observed. Vital signs were: pulse 112, respirations 18, blood pressure 132/86, oxygen saturation 96%. An IV (intravenous) was inserted by ambulance staff at 5:50 PM. The unit had been en route to another hospital, but was diverted at 5:59 PM, and had arrived at Wellstar Atlanta Medical Center at 6:24 PM.

Medical Record Review Wellstar Atlanta Medical Center
Review of Patient #19's medical record revealed that the fifty-eight year (58) old patient was transported by ambulance to the facility's emergency department on 6/19/16 at 6:38 PM with a complaint of high blood sugar.
The patient signed a Consent for Treatment, which included acknowledgment of receipt of Patient Rights and Advance Directive status on 6/19/16 at 7:45 PM.
The patient was triaged by a registered nurse on 6/19/16 at 6:52 PM, and designated as level 2 (emergent). Vital signs were: Temperature: 98.9; Heart Rate: 113; Respiratory Rate -18; Blood Pressure: 114/78; and oxygen saturation of 100% on room air. Pain 0/10. The nurse noted that EMS stated that the patient's blood sugar had been high for two (2) weeks, had blurred vision, and urinary frequency. The patient's behavior was agitated and anxious.
The D.O. (Doctor of Osteopathy) performed a medical screening examination on 6/19/16 at 7:07 PM, noting that Patient #19 was calm, cooperative, alert and oriented to person, place, and time, and was lucid. Patient #19 complained of high blood sugar (465) for eleven (11) days. Past medical history included coronary artery disease, (CAD), congestive heart failure, asthma, chronic obstructive lung disease (COPD), heart attack, diabetes, and post-traumatic stress disorder (PTSD).
Orders included:
7:07 PM: intravenous catheter, complete blood count (CBC), urinalysis
7:09 PM: urine drug screen
The orders were completed at 8:53 PM, which revealed a glucose of 540, and were negative for drugs.
Interventions: At 8:53 PM, an RN noted critical lab value- Glucose 540, confirmed and reported to the D.O.
Additional orders by the D.O. at 8:53 PM included: Normal saline, 1000 ml bolus Regular insulin 10 ten units IV (intravenously).

On 6/19/16 at 9:12 PM the D.O. noted that after obtaining consent, he/she had reviewed records of a recent hospitalization.
The D.O. had noted that Patient #19 had a history of substance abuse, and had ordered a urine drug screen on the patient. Patient #19 had become belligerent, was yelling, and refused further treatment because the drug screen was ordered.
On 6/19/16 at 9:37 PM, an RN noted that Patient #19 refused all treatments, and had become verbally aggressive and threatening to staff. The house supervisor was notified and came to speak to Patient #19. When Patient #19 continued to be aggressive, security was called. East Point police were called after patient #19 continued to be aggressive to all staff. The patient was escorted off the hospital property by the East Point police at 9:37 PM. There was no documentation in the medical record to indicate that on 6/19/2016 Patient #19 was informed/explained the risks and benefits of further treatment and evaluation.

Police Department Reports

The (name of city) Police Department incident investigation report dated 9/20/2016 at 11:31 was reviewed. The report narrative section revealed in part, "On September 20, 2017 at approximately 11:15 am, (police officers names)were dispatched to (Law Enforcement Center) ...to an incident occurred ... at (Atlanta Medical Center) ...Upon contact with the complainant Patient #19 , he stated that he was a patient at Atlanta Medical Center from June 6-15th 2016, and had asked for a patient advocate and was denied. Patient #19 had an argument with the doctor and was escorted out of the hospital by Police ...He was provided a victims' right card along with a case number."


The Transit Authority Police Department Supplemental Report dated 6/19/2016 was reviewed.
The report revealed in part, "On 6/19/2017 at 2155 (9:55 PM) while on patrol at (named transit station) I was dispatched to ...injured person at ....gate. I made contact with patient #19 who stated that his blood sugar levels was possibly high and requested an ambulance. (Name of Ambulance) rescue ...arrived on scene at 2202 (10:10 PM). Patient #19 was treated on scene, and transported to (Name of) acute care hospital for further evaluation."


Medical Record Review from Acute Care Hospital for Patient #19

The medical record review revealed that Patient #19 arrived at the acute care hospital on 6/19/2016 at 10:37 PM. Documentation by the attending physician on 6/20/2016 at 12:08 AM revealed in part, " ...58 year old ...with a history of CAD (Coronary Artery Disease) s/p (status/post) 5 vessel CABG (Coronary Artery Bypass Graft) in 2008, with placement of 3 stents this month, DM (diabetes Mellitus), HTN (Hypertension) ...presenting with Hyperglycemia and chest pain ...reports his blood glucose normally runs in the mid-high, 200s but for the past week it has been running in the 400s. He states he is fully compliant with his regimen of Lantus and insulin. For the past week, he has been experiencing worsening blurry vision, polyuria, anxiety, muscle spasms, diaphoresis, dry mouth, abdominal pain, nausea and increased thirst. He has also periods of retrosternal burning chest pain that radiates to this left arm and back and neck ...30 pound weight loss over the past month ...his troponin peaked at 0.18 on 6/7/16 ... Physical Exam: Constitution ...oriented to person, place and time ...appears well developed and well nourished... Vision intact to confrontation testing ...Midline sternotomy scar, well-healed Medical Decision Making: ...Blood glucose found to be 402, Anion Gap 11. Creatinine (measurement of Creatinine levels in blood to evaluate renal function) 2.0 (1.18 on 6/10/16 ...Troponin (testing done to diagnose heart attacks) <0.3 ...00:30 Will hydrate with NS (normal Saline), give Morphine ...admit to CDU (Clinical Decision {Unit for Observation}) for serial troponins and hydration ...8:27 am ...Discharge Summaries (Continued) Medical Decision Making Narrative ...CDU Course ...serial EKG's and cardiology consult. EKG showed diffuse TWI (T Wave Inversion) consistent with previous when stents were placed ...Cardiology saw patient and feel pain was not cardiac related given no EKG changes and neg (negative) trops (troponin).. .Patient had diabetes education consult and BG (blood glucose) has recovered to 252. Patient is ready for discharge to home with PCP (Primary Care Provider) and cardiology follow-up."

Policy and Procedure

Review of facility policy AMC-RI.280, Emergency Medical Treatment and Labor Act - EMTALA, effective 2/14/2001, reviewed/revised May 2017, revealed, in part, " ...V. PROCEDURE: ...F. Refusal of treatment
1. Of the hospital offers further examination and treatment and informed the individual or the person acting on the individual's behalf of the risks and benefits of not receiving the examination and treatment, but the individual or person acting on the individual's behalf refuses the examination and treatment, the Hospital shall take all reasonable steps to have the individual or the person acting on the individuals behalf acknowledge their refusal of further examination and treatment in writing (against medical advice form). Documentation in the medical record should include information provided to the individual or to the person acting on the individual's behalf. Documentation in the medical record should include information related to the medical screening exam, further examination, and treatment that is being offered to the individual including the risks and benefits of not continuing the examination and treatment.


Interviews

Telephone interview with the D.O. (Credential #5) on 5/31/2017 at 2:25 PM revealed that he/she had been employed in the facility's ER for approximately one and a half years, and had been trained in EMTALA. The D.O. stated that he/she wore scrubs with his/her name on them, wore a name badge, and always introduced him/herself to patients upon entering the room. The D.O. vaguely recalled patient #19, stating that he/she believed the patient had become upset when asked about a history of past drug use. The D.O. explained that patients had been found to be less than completely honest at times, while the physician needed to know if there was something else going on. The D.O. further stated that asking this question would usually not be upsetting to the patient, and, he/she didn't know if there was something else going on.

The D.O. stated that during an initial patient assessment, the physician would assess if the patient was under the influence or confused. The physician would assess the patient for appropriate eye contact, appropriate responses to questions, and ability to provide medical history beyond the present or previous day.
If the patient was alert and oriented to person, place, time, and situation, and able to make sound decisions, then, by law the physician could not do anything to force care. The patient can leave if they wish and can refuse treatment, even if he/she did not think it was in their best interest. The D.O. also stated that if a patient refused treatment, it is considered as refusing care. If a patient did not wish care, they are discharged. He/she further stated that discharge instructions were usually provided regardless of AMA status because his/her job was to take care of the patient. He/she also explained that staff called security if a patient became aggressive towards staff and that sometimes the house supervisor got involved to see if there was anything else that could be done, or if there was a misunderstanding. There was no documentation in the medical record to indicate that information related to further treatment was offered to Patient #19 on 6/19/2016 of the risks and benefits of not continuing treatment as stated in the facility's policy and procedure. There was also no documentation of a description of the treatment that was refused by patient.

Interview with the Director of Quality and Patient Safety on 5/31/2017 at 3:05 PM in the conference revealed that the security guard should have documented a report of the incident involving patient #19, but that none could be found. He/she also stated that the security guard was no longer employed at the facility.