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Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of examination and treatment was explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patients #2) sampled patients.

The findings included:

1. Review of the hospital policy "EMERGENCY MEDICAL AND TREATMENT AND LABOR ACT (EMTALA)" last revised 11/2020 revealed, "...an EMTALA obligation is triggered when the individual comes to a DED [Dedicated emergency Department] and:(1) the individual or representative acting on the individuals behalf requests an examination or treatment for a medical condition; or (2) a prudent layperson observer would conclude from the individuals appearance or behavior that the individual needs an examination or treatment of a medical condition...When an individual comes to [named hospital #1], and request is made for emergency care, [named hospital #1] must provide and appropriate Medical Screening Examination [MSE] within the capabilities of the facility emergency department...If a patient refuses the MSE or voluntarily chooses to leave prior to an MSE being performed, [named hospital #1] staff will assure, to the best of their ability, that the patient understood the risks of leaving and the benefits of an MSE. Documentation should include an explanation in the patients record and the completion of any required unit specific forms... If the patient expresses intent to leave the ED prior to receiving and MSE, the treating physician and/ or the nurse should explain the risks of leaving and encourage the patient to remain in the ED until receiving and MSE and necessary stabilization of any emergency medical condition..."

Review of the hospital policy "LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE (AMA)" revealed,"...Hospital wide...PURPOSE: To provide the patient with information regarding the risk associated with leaving the hospital Against Medical Advice (AMA) of a provider..." POLICY: [ named hospital #1] generally honors the decision of an adult with decision making capacity, as define below, to refuse treatment, including his or her decision to leave the facility AMA. Because patients have the right to self determination regarding their medical care, adult patients...may choose to discontinue treatment or leave the hospital without discharge orders or the providers approval. In this event, the provider will attempt to explain the possible complications and risks associated with leaving against medical advice and will document the event as specified...Documentation...The patient will be requested to sign the 'Leaving Against Medical Advice' (AMA) or Without a Medical Screen' form if the patient is still present. If the patient refuses, then the attempt should be documented on the form. Retain original copy of the completed form on the medical record..."

2. Medical record review for Patient #2 revealed a 46 year old male who presented to the ED on 6/14/2023 with complaints of shortness of breath and a history of sickle cell anemia. Patient #2 refused labs or imaging. There was no AMA documentation in the medical record.

Refer to A2407.

Based on policy review, medical record review and interview, the hospital failed to ensure the risks and benefits of examination and treatment was explained to all patients presenting to the emergency department (ED) seeking medical care and leaving against medical advice (AMA) for 1 of 21 (Patients #2) sampled patients.


The findings included:

1. Review of the hospital policy "EMERGENCY MEDICAL AND TREATMENT AND LABOR ACT (EMTALA)" last revised 11/2020 revealed, "...an EMTALA obligation is triggered when the individual comes to a DED [Dedicated emergency Department] and:(1) the individual or representative acting on the individuals behalf requests an examination or treatment for a medical condition; or (2) a prudent layperson observer would conclude from the individuals appearance or behavior that the individual needs an examination or treatment of a medical condition...When an individual comes to [named hospital #1], and request is made for emergency care, [named hospital #1] must provide and appropriate Medical Screening Examination [MSE] within the capabilities of the facility emergency department...If a patient refuses the MSE or voluntarily chooses to leave prior to an MSE being performed, [named hospital #1] staff will assure, to the best of their ability, that the patient understood the risks of leaving and the benefits of an MSE. Documentation should include an explanation in the patients record and the completion of any required unit specific forms... If the patient expresses intent to leave the ED prior to receiving and MSE, the treating physician and/ or the nurse should explain the risks of leaving and encourage the patient to remain in the ED until receiving and MSE and necessary stabilization of any emergency medical condition..."

Review of the hospital policy "LEAVING THE HOSPITAL AGAINST MEDICAL ADVICE (AMA)" revealed, "...Hospital wide...PURPOSE: To provide the patient with information regarding the risk associated with leaving the hospital Against Medical Advice (AMA) of a provider..." POLICY: [ named hospital #1] generally honors the decision of an adult with decision making capacity, as define below, to refuse treatment, including his or her decision to leave the facility AMA. Because patients have the right to self determination regarding their medical care, adult patients...may choose to discontinue treatment or leave the hospital without discharge orders or the providers approval. In this event, the provider will attempt to explain the possible complications and risks associated with leaving against medical advice and will document the event as specified...Documentation...The patient will be requested to sign the 'Leaving Against Medical Advice' (AMA) or Without a Medical Screen' form if the patient is still present. If the patient refuses, then the attempt should be documented on the form. Retain original copy of the completed form on the medical record..."

2. Medical record review for Patient #2 revealed 46 year old male with a history of sickle cell disease who presented to Hospital #1's ED on 6/14/2023 at 4:10 PM via private vehicle with complaints of shortness of breath. Triage was initiated at 4:18 PM and a nurse documented,"PT [patient] sent over from the clinic for further work up, states he has pneumonia and is in sickle cell crisis..." Patient #2's vitals were recorded as: Blood pressure- 98/54, temperature- 98.4, Respirations- 18, Oxygen level 99% on room air and pulse- 68 beats per minute. Patient #2 was assigned an acuity level "urgent" by the triage nurse. A MSE was initiated at 5:23 PM by an ED Attending Physician. Progress notes by the ED Attending Physician at 5:35 PM revealed, "ER team spoke with heme- onc [hematology -Oncology] team who recommended a full work up as patient wants further management. If patient is refusing lab work, given that the patient has normal vitals patient can follow up outpatient with primary care and heme- onc. Options were discussed with patient that if he would like to be worked up for sickle cell crisis and possible pneumonia, lab work and imaging would need to be pursued. Patient continued to refuse. The alternative option was discussed with patient that he can be given 1 (one) dose of his home medication for pain and then he would be discharged home to follow up with heme-onc and PCP [primary care provider]. Patient agreed to this plan. Patient is also asking for antibiotics to be prescribed, however ER team declined as patient is refusing any lab work and imaging. Patient understands the consequences of not being worked up if he is undergoing a pain crisis." Patient #2 was administered Oxycodone 30 milligrams for pain at 6:01 PM. The ED Attending Physician documented, "...Patient care discussed with [named ED Physician #1] and [named Hematology/ Oncology Mid-level Provider]...discharged home to follow up with PCP and heme-onc..." Patient #2 was discharged from the ED on 6/14/2023 at 5:58 PM. There was no documentation of an AMA form that included the risk and benefits of leaving the ED without further care/ testing to determine if an emergency medical condition existed.

3. In a telephone interview on 7/13/2023 at 8:55 AM, the ED Nursing Director stated, "Against medical advice is leaving and not staying here...He [Patient #2] said I want treatment but not what you are offering me...the [Patient #2] was not an AMA." When asked who was responsible for completing the AMA documentation in the ED, the ED Nursing Director stated both the nurse and physician.

In a telephone interview on 7/13/2023 at 9:03 AM, the Interim Director of Quality stated there was one AMA policy for the hospital that also covered the Emergency Department.

In a telephone interview on 7/18/2023 at 11:00 AM RN #1 verified she provided care in the ED for Patient #2 on 6/14/2023. RN #1 stated Patient #2 was a sickle cell patient, and he was adamant about what he wanted and didn't want. RN #1 stated the ED Physician reached out to Patient #2's sickle cell provider to explain he was refusing all tests/ labs and the decision was made to offer him medication to treat the pain and discharge him home with instructions to follow up with his provider/clinic. When asked how she made the determination to complete AMA paperwork, RN #1 stated, "If he [Patient #2] had not agreed to seek alternate care [from his provider] ..."

The ED Attending Physician who provided care for Patient #2 on 6/14/2023 was out of the country and unavailable for interview during the investigation. ED Physician #1 was the Attending's supervising Physician and also saw and provided care to Patient #2.

In a telephone interview on 6/29/2023 at 11:08 AM, ED Physician #1 stated Patient #2 refused labs and X-rays and he was alert and oriented with the capacity to refuse. ED Physician #1 stated "...if I can't do any diagnostic studies...limited ability to provide care." ED Physician #1 stated Patient #1 was treated for pain and discharged home to follow up with his clinic that managed his sickle cell disease.

In a telephone interview on 7/18/2023 at 11:20 am, ED Physician #1 stated there was no legal requirement to complete an AMA form. ED Physician #1 stated "I did not have any reason to advise him [Patient #2] to remain [in the ED]...his vitals were stable." Physician #1 stated, "I documented everything that was discussed with the patient."