HospitalInspections.org

Based on record review and interview the facility failed to follow facility policy when discharging a patient AMA (against medical advice) in 2 of 2 records reviewed (Patient # 1 and 10) where a patient left AMA and failed to follow facility policy when transferring an inpatient to another acute care facility in 1 of 1 records reviewed where an inpatient was transferred out to another hospital in a total of 10 records reviewed.

Findings:

Review of the facility policy titled, "Leaving Against Medical Advice (AMA) Policy" document ID TM7XN2FTXHRM-3-219 dated 3/8/2023 revealed, "3.1 A competent adult patient...has the right to refuse or withdraw from care, treatment, or a service or leave the healthcare facility...d. Have the patient sign the AMA form (Leaving Against Medical Advice Release). If the patient refuses to sign, read the form to the patient, make a specific notation of the patient refusal to sign the form and have two witnesses sign the form as acknowledgement of the patient's refusal to sign. e. The witnessed release form is placed in the patient's medical record...f. Once AMA is processed, an incident report is entered into RL Solutions (the facility online incident reporting system) under Patient Behavior..."

Review of Patient #1's medical record revealed an AMA discharge on 4/20/2023. Nurses Note in the record dated 4/20/2023 at 2:40 PM revealed, "Patient refused to sign the AMA form at this time." There was no AMA form witnessed by two in the medical record. There was no incident report entered into RL Solutions.

Review of Patient #10's medical record revealed an AMA discharge on 6/7/2023. There was no incident report entered into RL Solutions.

In an interview on 6/13/2023 at 3:10 PM with Supervisor F when asked about the lack of a witnessed AMA form for Patient #1 stated, "It's not there, they must have forgot."

In an interview on 6/13/2023 at 3:05 PM with Quality B, Quality B confirmed that neither Patient #1 or #10 had incident reports entered in RL Solutions per policy.

Review of the facility policy titled, "Hospital to Hospital Transfer Process" document ID KT2N6QC5SZE5-3-1918 dated 3/29/2022 revealed, "...3.1 Physician: f. MMC (Marshfield Medical Center) MD signs appropriate paperwork for transport...3.3 RN completes the following...c. Pulls the transfer packet...d. Obtains patient or responsible persons signature on transport forms in packet...f. Gathers needed paperwork listed on front of transport envelope...h.RN calls report to receiving facility...and completes transfer/handoff sheet in Logicare..."

Review of Patient #10's medical record revealed a transfer to University of Wisconsin Hospital on 6/7/2023. No transfer forms were found in the medical record.

In an interview with Quality B on 6/13/2023 at 3:30 PM Quality B stated that the forms should have been scanned into the medical record and that they are not there. "We called the receiving hospital and they could not locate any transfer forms with the patient's medical record either."