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Based on reviews of medical records and the hospital's policies and procedures the hospital failed to explain the risks and benefits of refusal for further treatment for 1 (#2) of (twenty) 20 sampled patients who presented to the emergency department. Refer to findings in Tag 2407.

Based on reviews of medical records and the hospital's policies and procedures the hospital failed to explain the risks and benefits of refusal for further treatment for 1 (#2) of (twenty) 20 sampled patients who presented to the emergency department.

Findings:
The facility's EMTALA policy and procedure, PolicyStat ID: 1307120, Original: 08/2008, Approved: 05/2015 was reviewed. Review of the section of the policy titled " Refusal to Consent to Treatment " page 11 of 13 revealed in part, " a. Written Refusal-Partial Refusal of Care or Against Medical Advice. If a Physician or QMP (Qualified Medical Personnel) has begun the medical screening examination or any stabilizing treatment and an individual refuses to consent to a test, examination or treatment or refuses any further care and is determined to leave against medical advice, after being informed of the risks and benefits and the hospital's obligation under EMTALA (Emergency Medical Treatment and Labor Act), reasonable attempts shall be made to obtain a written refusal to consent to examination or treatment using the form provided for that purpose or document the individual's refusal to sign the Partial Refusal of Care or the Against Medical Advice Form ...The medical record must contain a description of the screening and the examination, treatment , or both if applicable, that was refused by or on behalf of the individual."
Review of the "Emergency Patient Record" revealed that Patient #2 presented to the facility on 6/15/2015 at 3:10 a.m. The emergency department (ED) documented the"Subjective Assessment: Pt (patient) punched wall. WENT TO____ (acute care hospital name) DX (diagnosed) WITH OPEN FX (fracture) R (right) HAND. ____ (acute care hospital name) WANTED TO TRANSFER PT. PT WALKED OUT AND CAME HERE. " The patient ' s Chief Complaint was " Extremity Pain/Injury " . Patient #2 ' s Triage level was " ESI (Emergency severity Level) 3/Urgent. " Documentation by the ED nurse revealed the extremity assessment included the mechanism of injury was blunt trauma, the presenting signs and symptoms was edema at injury, extremity discomfort, and decreased range of motion of the left hand. The patient's onset of symptoms was 6/14/2015 at 10:00 p.m. Further review revealed that on 6/15/2015 at 3:38 a.m., an x-ray of the left had was ordered by the ED physician. The disposition of the patient was documented by the ED nurse as, Disposition Category: [Refused Treatment] Discharged ....Emergency Notes ...6/15/2015 0351 ...THE PATIENT VOLUNTARILY DEPARTS AT THIS TIME. THE PATIENT WAS MAKING COPULATORY REMARKS AND EXTENDING THE THIRD DIGIT OF HIS RIGHT HAND TOWARD THE NURSING STAFF AS HE WALKED PAST THE NURSING STATION. "
The Emergency Provider Report dated 6/15/2015 was reviewed. Documentation by the Physician Assistant (PA) revealed that patient #2 -was seen at 3: 20 a.m. The PA documented the patient ' s chief complaint was " hand injury. " The Physical Examination revealed in part, " Hand: Normal pulse, no compartment syndrome, normal tendon function, swelling (DISTAL 5TH METACARPAL), abrasion ....Neurologic: No motor deficits, no sensory deficits. Disposition: Extremity Inj (injury) Upper Clinical Impression: HAND CONTUSION/HAND PAIN) (Disposition ...Screened and discharged. "
The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure there was documentation in the medical record to indicate a discussion of the risks and benefits of further treatment (x-ray) and/or a description of the treatment that was refused by patient #2 on 6/15/2015.