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UNITED METHODIST BEHAVIORAL HOSPITAL
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on policy review, Utilization Review for third quarter 2017 through second quarter 2018, and interview, it was determined the facility failed to ensure an incident report was generated per policy whenever a patient refused treatment and was discharged AMA (Against Medical Advice) for 71 of 71 patients. The failed practice did not ensure the Director of Nursing (DON) was aware of all AMA discharges in the event measures needed to be taken to prevent such discharges. The failed practice had the likelihood to affect any patient refusing treatment and requesting an AMA discharge. Findings follow.
A. Review of policy titled "Against Medical Advice (AMA)" showed, "If the Attending Physician decides to discharge AMA ...Complete Incident Report and forward to DON."
B. Review of Utilization Reports for third quarter 2017 through second quarter 2018 showed a total of 71 patients who were discharged AMA.
C. During an interview on 08/02/18 at 3:40 PM, the Corporate Compliance Director confirmed the DON had "never done one of those" (an incident report related to AMA discharge).