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Based on review of the Regional Medical Center of Central Alabama (RMCCA) Medical Staff Rules and Regulations, facility policies and procedures titled, Emergency Medical Treatment and Patient Transfer Policy Hospital-Wide, Assessment and Reassessment of Patients (5 Tier), Pain Management Policy Hospital-Wide (RMCCA), Patient Leaves Against Medical Advice/Leaves Without Treatment (AMA/LWOT), the facility ER (Emergency Room) Log report, ED (Emergency Department) medical record (MR) documentation and staff interviews, it was determined the ED staff failed to complete MR documentation and ensure all patients who refused to consent to treatment were informed and provided a description of the examination, proposed treatment(s) and specific risks involved for 4 of 6 patients who left AMA/LWOT.

In addition, the ED staff failed to follow their own facility polices and procedures and ensure ED MR documentation also included:

1) Completion of the AMA documentation with exactly what treatment and instructions were advised, with thorough documentation.

2) Discussion and documentation of the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient.

3) Provision of written instructions and recommendations for follow up with his/her family physician or return to the ED if his/her condition worsens provided to the patient at discharge.

4) Documentation of instructions of potential risks and complications, the patients condition prior to leaving the ED, and patient's mental status and objective behavior.

5) Documentation of efforts made to prevent the patient(s) from leaving AMA and re-assessment of the patient's health status at discharge including VS (vital signs-pulse, respiration rate, BP [blood pressure].

This affected Patient Identifier's (PI) # 2, PI # 1, PI # 4, PI # 9 and had the potential to negatively affect all patients who present to the ED for treatment.

Findings include:

Refer to A 2407 for findings.

Based on review of the Regional Medical Center of Central Alabama (RMCCA) Medical Staff Rules and Regulations, facility policies and procedures titled, Emergency Medical Treatment and Patient Transfer Policy Hospital-Wide, Assessment and Reassessment of Patients (5 Tier), Pain Management Policy Hospital-Wide (RMCCA), Patient Leaves Against Medical Advice/Leaves Without Treatment (AMA/LWOT), the facility ER (Emergency Room) Log report, ED (Emergency Department) medical record (MR) documentation and staff interviews.

It was determined the ED staff failed to complete MR documentation and ensure all patients who refused to consent to treatment were informed and provided a description of the examination, proposed treatment(s) and specific risks involved for 4 of 6 patients who leaves AMA/LWOT.

In addition, the ED staff failed to follow their own facility polices and procedures and ensure ED MR documentation also included:

1) Completion of the AMA documentation with exactly what treatment and instructions were advised, with thorough documentation.

2) Discussion and documentation of the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient.

3) Provision of written instructions and recommendations for follow up with his/her family physician or return to the ED if his/her condition worsens provided to the patient at discharge.

4) Documentation of instructions of potential risks and complications, the patients condition prior to leaving the ED, and patient's mental status and objective behavior.

5) Documentation of efforts made to prevent the patient(s) from leaving AMA and re-assessment of the patient's health status at discharge including VS (Vital Signs - pulse, respiration rate, BP [Blood Pressure].

This affected Patient Identifier's (PI) # 2, PI # 1, PI # 4, PI # 9 and had the potential to negatively affect all patients who present to the ED for treatment.

Findings include:

Regional Medical Center of Central Alabama Rules & (and) Regulations

These Rules & Regulations are adopted in connection with the Medical Staff Bylaws and made a part thereof. The definitions and terminologies of the bylaws also apply to the Rules & Regulations and proceedings hereunder.

Article V

Emergency Care Services

5.1 Emergency Department Functions

5.1 (a) To give adequate Medical Screening Examination and initial stabilization treatment or Medical Screening Examination to every person who considers him/herself acutely ill or injured and presents for Emergency care or requests Medical Screening Examination.

...5.4 (a) Emergency Medical Screening Examination

(i) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an "emergency medical condition" is defined as a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, active labor, such that the absence of immediate attention could reasonably be experienced to result in placing the patient's health...in serious jeopardy, serious impairment of bodily function or serious dysfunction of any body part or organ.

(iv) Services available to the Emergency Department patients shall include all ancillary services routinely available to the Emergency Department...

5.4 (b) Stabilization

(1) Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, excepting conditions set forth below.

(2) A patient is Stable for Discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up treatment care with the discharge instruction; or, the patient requires no further treatment and the treating physician has provided written documentation of his/her findings.

(4) A patient does not have to be stabilized when....

(5) If a patient refuse to accept the proposed stabilizing treatment, the Emergency Department Physician, after informing the patient of the risks and benefits of the proposed treatment and the risks and benefits of the individuals' refusal of the proposed treatment, shall take all reasonable steps to have the individual sign a form indicating he/she has refused treatment. The Emergency Department Physician shall document the patient's refusal in the patient's chart, which refusal shall be witnessed by the Emergency Department supervisor or designee. If the patient so desires, the patient will be offered assistance in finding a physician for outpatient follow-up care.

Regional Medical Center of Central Alabama (RMCCA)
Policy Title: Emergency Medical Treatment and Patient Transfer Policy Hospital-Wide
Revision Date: 10/5/18

Purpose:

This emergency medical treatment and patient transfer policy is based on federal law relating to emergency medical treatment and medically appropriate transfer of individuals between hospitals. The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, religion, national origin, age, sex, physical condition, or economic status.

III. Administrative Procedures

C. Refusal to Consent to Treatment or Transfer

1. Refusal to Consent to Treatment or Transfer. If an individual refuses to consent to examination or treatment, after being informed of the risks and benefits and the Hospital's obligations under these rules, reasonable attempts shall be made to obtain a written refusal to consent to treatment or examination on the form provided for that purpose. The individuals medical record shall contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual...

IV. Enforcement

The Hospital will enforce this Emergency Medical Treatment and Patient Transfer Policy in the same manner as it enforces the other policies and procedures for the governance of the Hospital.

Compliance Program Policy Statement:

...Failure to comply with this policy shall constitute a serious violation of policy and shall subject an employee to disciplinary action, up to and including suspension or discharge.

Regional Medical Center of Central Alabama (RMCCA)
Policy Title: Assessment and Reassessment of Patients (5 Tier)
Revision Date: 3/7/19

Purpose:

A. To identify patient care needs.

I. Policy:

A. Patients presenting to the Emergency Department should be assessed for physical, psychological and social status to identify patient's care needs.

C. The Emergency Department will follow hospital wide policy for assessment/reassessment, which provides for care and assessment/reassessment time frames.

Procedure:

A. Assessment of the emergency department patient should begin at triage...

B. Assessment should be initiated...after the patient is placed in the treatment area. The scope and intensity of this assessment is determined by the patient's condition, complaint/diagnosis, the care setting and response to previous care, as well as the patient's desire for care.

C. Each patient should have a Medical Screening Exam (MSE) by a physician.

D. The...MSE may or may not include, but is not limited to diagnostic laboratory testing...radiology, and other...procedures as indicated to determine the patient's health care or treatment needs.

I. Emergency Department patients are monitored and reassessed at regular intervals as patient condition indicates based on response to care, significant change in condition, diagnostic test results, and information from various assessments of the patients.

J. Patient Reassessments will be done in a timeframe appropriate for the patient's condition. Reassess body systems are indicated per patient condition and severity. Note psychosocial status, treatments, diagnostics and any other pertinent data changed from last assessment. Minimally, nursing reassessments will be done according to hospital policy:

1. Category I Emergent- Continuous reassessment:
2. Category II Semi-emergent-As often as needed; not to exceed 30 minutes;
3. Category III Urgent-as often as needed; not to exceed 2 hours...

K. Both physicians and nurse should utilize continuing notes on the....patients to assure aspects of assessment and care are adequately documented.

L. RN (Registered Nurse) will complete appropriate nursing records on every patient. Other licensed providers can assist on gathering data related to this process.

M. Vital signs (VS) should be taken at least every 2 hours until discharge...Vital signs will be taken on all patients upon discharge ( with the exception of non-urgent patients)...

Regional Medical Center of Central Alabama (RMCCA)
Policy Title: Pain Management Policy Hospital-Wide

Pain Management

I. Patient's Rights:

A. Patients have the right to appropriate assessment and management of pain.
B. The patient's right to pain management is respected...supported by the healthcare team...
Staff encourages the reporting of pain.
C. Our goal is to ensure optimal patient comfort by responding quickly to reports of pain...

Initial Assessment:

A. Pain assessment...completed during the initial nursing assessment.

III. Pain Scale:

A. Use a pain intensity scale...

C. Use the same rating scale each time

D. Types of Pain Scales

1. Numeric Scale: 0-10 (0-no pain, 10-worst pain)

IV. Plan:

V. Interventions:
A. Pain management will be individualized for each patient.
B. Physician to order medication of choice...
C. Non-pharmacological management pain should be considered for each patient... cold...repositioning

VI. Assessment/Reassessment:

B. Routinely, at regular intervals
C. All levels of pain...severe [7-10] are reassessed every 2 hours...
E. Pain is reassessed at discharge.
F....re-assessed with frequent rounding done by nursing staff.

VII.. Documentation:

A. Assessment and measure of pain intensity... recorded electronically...

Pain Management Evaluation:

A. The goal of pain management is to evaluate the patient's perception of the appropriateness and effectiveness of pain management...

Regional Medical Center of Central Alabama (RMCCA)
Policy Title: Patient Leaves Against Medical Advice/Leaves Without Treatment
Revision Date: 10/6/2018

...Purpose:

A. To establish procedure for documentation of patients leaving against medical advice (AMA) or leaving without treatment (LWOT).

I. Policy:

A. When a patient leaves the Emergency Department AMA, the medical record should reflect exactly what treatment and instructions were advised, with thorough documentation. All patients indicating a desire to leave against medical advice shall be provided an AMA form to sign.

II. Procedure:

A. Emergency Department and Registration Staff may inform the patient that you are notifying the physician that the patient wishes to leaves prior to completion of tests or treatment. Notified staff should request that the patient remain to discuss the situation with the physician.

B. The Registered Nurse and/or Physician shall discuss and document, with the patient and/or family, the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient.

C. After explanation of potential risks and consequences, if the patient refused to wait for the physician, or if the patient talks to the physician and still desires to leave 'against medical advice', request that the patient sign the AMA form.

D. The Registered Nurse shall provide written instructions to the patient to follow up with his/her family physician or return to the Emergency Department if his/her condition worsens.

E. If the patient refuses to sign the form, complete the form except for the patient's signature, sign across the signature area that the patient refuses to sign and have a second witness sign the form.

F. Document on the chart:

1. The patient's desire to leave AMA and specific reasons stated by the patient for leaving;
2. Instructions on potential risks and complications;
3. Patient's condition prior to leaving the Emergency Department;
4. Patient's mental status and objective behavior:
5. What efforts were made to prevent the patient from leaving AMA and what attempts were made to secure consent; and
6. Written instructions and recommendations for follow-up given to patient...

I. All patients who leave after triage/leave without treatment (LWOT) or who leave after the physician exam (AMA) should be entered into the ER (emergency room) patient daily log. All patients who leave prior to triage will be on the ER "Discharge" log with a note.

J. In the event the patient leaves prior to an evaluation by the physician and does not notify any staff member of leaving; the Registered Nurse shall document the elopement or the patient in the nursing notes.

1. Review of the ER Log report dated 8/8/19 revealed PI # 2 presented to RMCC's ED on 8/8/19 at 4:37 PM with chief complaint, ankle injury. The ED Log report discharge date was 8/8/19 at 9:30 PM and the discharge code, L AMA (left AMA).

Review of PI # 2's ED presentation on 8/8/19 revealed ED registration was 4:37 PM. Employee Identifier (EI) # 4, ED RN, completed the triage at the triage station at 4:55 PM. The presenting history documented was right ankle injury, pain present, pain scale rating 7, pain quality, aching and throbbing, exacerbating factors documented were movement, walking, weight bearing. EI # 4 assessed the Triage Level: 3-URGENT. The triage VS, BP 130/85, and pulse 82 beats/minute.

Review of EI # 4's 8/8/19 physical assessment documentation completed at 4:59 PM included musculoskeletal system documentation that revealed the right lower extremity, "neurovascularly intact", distal pulse strong, skin warm, motor function deficit.

Review of the ChartLink Physician Entered Orders revealed a verbal order dated 8/8/19 at 4:49 PM for routine urine pregnancy test. At 6:05 PM, the urine pregnancy results reported were "negative" and at 7:01 PM, the ChartLink Physician Entered Orders included right ankle x-ray.

There was no treatment orders to address the triage pain assessment, pain rating 7 and no pain interventions were documented.

Review of the 8/8/19 ED Patient Progress Note documentation at 8:40 PM, which was 3 hours 45 minutes later, revealed PI # 2's VS, BP 139/102, pulse was 87.

There was no documentation the ED staff re-assessed PI # 2 for changes in the health status at least every 2 hours following the URGENT -Triage level 3 screening which included a pain re-assessment.

Review of the ED record revealed a Preliminary Report Exam, Reason XR (x-ray-an electromagnetic wave of high energy and very short wavelength, which is able to pass through many materials opaque to light) Ankle, Right, dated 8/8/19 18:02 (6:02 PM), Date Received 8/8/19 21:24 (9:24 PM), Date of Transcription 8/8/19 21:28 (9:28 PM). Reason documented, Fracture of the inferior tip of lateral malleolus.

Review of the ED record revealed a Refusal of Treatment/Services Release for Responsibility (AMA) form completed by EI # 7, ED, RN, which contained the following documentation:

...This is to certify that I, (PI # 2's handwritten name), am refusing the following treatment(s) or services against the advice of my physician:

Service (specify): handwritten entry was "eval (evaluation) & Tx (treatment)."
Treatment (specify): was left blank, no treatment was specified or documented.
Risks involved: was left blank, no potential or risks were specified or documented.

I am leaving L.V. Stabler Memorial Hospital [RMCCA] at my own insistence and against the advice of my physician(s) (AMA).

Further review of the last paragraph of the Refusal of Treatment/Services Release From Responsibility (AMA) revealed the following documentation:

"Instructions: 1) Notify physician. 2) Document risks of leaving. 3) Have patient sign AMA form..."

PI # 2's signature was documented on the AMA form dated 8/8/10 2130 (9:30 PM) with a witness signature, EI # 7, ED RN, dated 8/8/19 2130.

Review of the Miscellaneous Nursing Note documentation dated 8/8/19 at 9:32 PM revealed the "pt (patient) came up to the desk insisting on leaving since she/he has been here since 4pm. Pt signed her/his AMA papers and ambulated out of facility."

Review of the ED Summary Report dated 8/8/19 at 9:34 PM completed by EI # 7 revealed the following documentation:

"Disposition: Left AMA
Accompanied by: Patient
Instructions Given to: Patient
ED Departure Date/Time: 08/08/2019 21:35 (9:35 PM)
Patient Status: Discharge"

There was no medical record documentation ED staff notified the ED Physician of PI # 2's desire to leave AMA. There was no documentation what the specific risk(s) involved were by leaving AMA, and no specific documentation of the proposed treatment/s the patient had refused. There was no documentation of the patient's condition at discharge, including discharge VS. PI # 2's mental status/objective behavior was not documented prior to leaving the ED. There was no documentation that any efforts were made to prevent PI # 2 from leaving AMA and no documentation of any written/verbal instructions provided to PI # 2. There were no recommendations for follow-up documented in the medical record.

2. Further review of the ER Log report documentation revealed a second ED visit for PI # 2 on 8/8/19 at 10:19 PM, which was 44 minutes after PI # 2 was discharged from the ED, earlier the evening of 8/8/19. The chief complaint documented, right ankle injury. The discharge date was 8/8/19 at 11:35 PM.

Review of the ED record documentation for PI # 2' s second ED presentation on 8/8/19 revealed that EI # 6, ED, RN, completed the triage at 10:24 PM, the history and presenting problem(s), right ankle pain. PI # 2's VS, pulse 89, BP 135/94 and Triage Level: 3- URGENT.

At 10:51 PM, EI # 6 documented the Pain Assessment, pain scale: 7, pain location, right lower extremity, pain with activity: 10, pain quality-aching, exacerbating factors, walking, relieved by rest. The musculoskeletal assessment of the right lower extremity revealed, "neurovascularly" intact, distal pulse strong, skin warm/intact, tenderness, capillary refill less than 3 seconds. Motor function intact.

Review of the ED Physician documentation dated 8/8/19 at 11:18 PM revealed the chief complaint, stepped in a hole about 1600 (4:00 PM) twisting right ankle and hearing a pop.

Review of the ED physician's history of present illness dated 8/8/19 at 11:18 PM revealed "...pain along the lateral malleolus...developed swelling and tenderness...was here earlier in the evening we had a big rush of chest pain patients and a stroke several transfers. (She/he) waited several hours then left AMA. I reviewed his/her xrays however and (he/she) did have a nondisplaced fracture of the tip of the right fibula. (He/she) now returns for treatment."

Review of the ED Physician's physical exam documentation revealed extremities warm without cyanosis, clubbing or edema. No evidence of trauma or dislocation, Full range of motion, no evidence of deep vein thrombosis, negative Homan sign. Swelling and tenderness over right lateral bone ankle. Grossly stable.

Review of EI # 6's ED Nursing Documentation dated 8/8/19 at 11:22 PM revealed a stirrup type splint to the posterior right ankle was applied and crutches were provided.

Review of the ED Physician's diagnosis documentation at 8/8/19 11:23 PM, Fracture of right ankle, initial Encounter for closed fracture. The 8/8/19 ED Provider Note documentation revealed Toradol 60 (mg) milligram IM (intramuscular) was prescribed and administered at 11:22 PM by EI # 7. Prescriptions were Ibuprofen 600 mg tid (3 times a day) PC (after meals) prn (as needed) pain and Norco 7.5/325 # 6, one qid (4 times a day) prn pain. The Provider Evaluation notes revealed PI # 2 had a posterior splint right lower leg and crutches, advised elevation, ice and follow up with named physician in the next morning with the physician's phone number documented.

Review of the ED Nursing Documentation dated 8/8/19 at 11:36 PM, revealed the disposition, discharged, prescriptions/instructions given to patient, patient verbalizes understanding of instructions, discharged home per private auto, ambulatory, crutches.

Further review of PI # 2's ED medical record documentation contained 2 pages of discharge instructions titled, Leg Fracture.

A phone interview on 8/15/19 at 10:35 AM was conducted with EI # 4, the ED RN, who performed the 8/8/19 4:55 PM initial ED presentation triage/nursing assessment. EI # 4 stated he/she reported PI # 2's chief complaint/triage/nursing assessment findings to the ED Physician, EI # 3, and orders were received for a urine pregnancy test and an ankle X-ray. EI # 4 stated he/she did not think PI # 2's ankle was broken because PI # 2 ambulated into the ED. EI # 4 confirmed a 7 (severe pain) rating was assessed and no pain management was provided during the day shift on 8/8/19. EI # 4 stated around 6:00 PM, the ED had 3 chest pain patients arrive and at shift change around 7:00 PM, no MSE had been completed and the x-ray results was not complete.

In a phone interview on 8/15/19 at 11:25 AM, EI # 7, ED RN, who also was on duty in the ED the night of 8/8/19, stated PI # 2 came to the nurse desk, asked how much longer, my response was I'm not sure. PI # 2 reported he/she was ready to leave, and EI # 7 stated I got out the AMA paperwork while EI # 6 talked to PI # 2. EI # 7 reported she left the nurses desk and upon return PI # 2 was not present. EI # 7 stated from what I understood, the x-ray came back abnormal.

During a phone interview on 8/15/19 at 11:59 AM, EI # 5, ED LPN (Licensed Practical Nurse) reported she was pulled from regular duties to assist the night shift ED RN's on 8/8/19. EI # 5 stated she took PI # 2's VS earlier in the shift (at 8:40 PM) and was instructed around 10:00 PM by EI # 3, the ED Physician, to phone PI # 2 and request return to the ED because the patient had a broken foot. EI # 5 stated PI # 2 returned to the ED.

In addition, EI # 5 confirmed she may not have documented the ED Physician order/instructions and conversation with PI # 2 in the ED medical record.

There was no medical record documentation ED staff notified PI # 2 by phone to return to the ED for a complete MSE and stabilizing treatment.

In an interview on 8/15/19 at 1:12 PM, EI # 8, ED Registration Clerk, stated she witnessed PI # 2 leaving the ED "limping" and was told by PI # 2 he/she had a leg injury, had been here awhile, and had not been seen by the doctor.

In addition, EI # 8 stated she completed PI # 2's ED return visit registration and stated PI # 2 reported to her the ED staff called and requested he/she return to the ED because of an ankle fracture.

In an interview on 8/15/19 at 1:45 PM, ED Physician, EI # 3, stated on 8/8/19 the evening shift the ED had 3 patients present with chest pains, a stroke and several transfers. EI # 3 stated there may have been patients who left without treatment (LWOT) that evening.

On 8/16/19 at 8:34 AM, during a phone interview, EI # 6, ED RN, confirmed he worked the ED night shift on 8/8/19, and stated the ED was full evening of 8/8/19 with long wait times.

During the interview, EI # 6 stated PI # 2 "approached the nurses station several times, asked how much longer, then finally asked if there was anything he/she needed to sign, he/she would see someone tomorrow? " EI # 6 stated EI # 7, ED RN and EI # 3, ED Physician, were at the nurses station at that time. EI # 6 stated the ED MD told PI # 2 he would get to him/her as soon as possible." The surveyor asked EI # 6 if PI # 2 inquired about test results? EI # 6 stated, "maybe he/she did, maybe EI # 3 said the x-rays were negative...When EI # 3 did see the report, he said call this young man/lady back, he/she has a fracture." EI # 6 stated PI # 2 returned to the ED, the ankle was splinted, pain medication was administered, prescriptions were provided and PI # 2 was instructed to follow-up with a local orthopedic physician the next morning.

During an interview on 8/16/19 at 10:13 AM, EI # 1, Chief Nursing Officer (CNO) confirmed PI # 2's ED medical record failed to contain documentation that ED staff re-assessed PI # 2 for changes in the health status at least every 2 hours per ED policy for Triage Level 3, and that ED staff notified the ED Physician of the AMA/LWOT. The AMA documentation failed to include a description of the examination and proposed treatment(s) PI # 2 had refused and no risks were documented. There was no medical record documentation ED staff provided written instructions, no recommendation for follow-up and no discharge instructions provided.

In an interview on 8/16/19 at 10: 13 AM, EI # 1 confirmed the facility policies were not followed for re-assessment of PI # 2 and AMA documentation completion.

3. Review of the ER Log report dated 8/8/19 revealed PI # 1 presented to the ED on 8/8/19 at 5:48 PM, chief complaint was short of breath (SOB), difficulty. The ED Log report discharge date was 8/8/19 at 7:49 PM, the discharge code, L AMA (left against medical advice).

Review of PI # 1's ED presentation on 8/8/19 revealed ED registration was 5:47 PM. The ED Nursing Triage documentation revealed PI # 1 was triaged at the triage station at 5:49 PM. The presenting history, "having SOB and coughing, went to primed Monday..." The assigned Triage Level: 3-URGENT.

Review of the 8/8/19 ED Nursing Documentation physical assessment findings documented at 6:05 PM revealed a moist cough and clear lung sounds, non labored-breathing pattern, respiration rate 18/minute, oxygen saturation 99 %.

Review of the 8/8/19 ED Provider Note documentation at 7:00 PM revealed a history of asthma and bronchitis, reportedly had a steroid shot 3 days ago and was on daily prednisone. Duoneb was administered which did help the dyspnea significantly. Chest x-ray revealed no acute pulmonary disease.

Further review of the 8/8/19 ED Provider Note documentation revealed physical exam findings that PI # 1 was "...somewhat anxious...Limited exam...bilateral expiratory wheezes and few scattered rhonchi...Patient signed out AMA prior to further evaluation...did advise the nurse he/she was breathing lot better and would just follow-up with (named physician) tomorrow."

Review of the 8/8/19 Patient Progress Note documentation revealed at 7:12 PM, Ipratropium-Albuterol nebulizer was administered by the ED RN and PI # 1 refused Decadron 8 mg IM.

At 6:08 PM, a CMP (complete metabolic profile) and Hematology was ordered, collected at 6:15 PM, results were complete at 7:12 PM.

Review of the 8/8/19 7:40 PM ED Miscellaneous Nursing Note documentation revealed "patient approaches staff and states need to leave. MD is at the NS (nurse station) and is aware of patient's desire. AMA signed and patient ambulates from the ER." There was no documentation of any efforts by ED staff to avoid the AMA discharge.

Further review of the 8/8/19 ED Nursing Documentation revealed PI # 1 left AMA, AMA disclosure signed, instructions given to patient, ER departure, 7:42 PM, Patient Status, Discharge.

There was no patient re-assessment at discharge which included VS.

Review of the ED Provider Note plan documentation dated 8/9/19 at 2:36 AM revealed medication prescribed this visit, none, left before evaluation complete. The ED Provider Evaluation Notes documentation revealed PI # 1 received 1 DouNeb, felt better, elected to leave AMA, has appointment with named physician in a.m. (morning), Return as needed.

Review of the PI # 1's ED record included a Refusal of Treatment/Services Release for Responsibility (AMA) form that contained the following documentation:

...This is to certify that I, (handwritten name for PI #1), am refusing the following treatment(s) or services against the advice of my physician:

Service (specify): handwritten documentation entered was "evaluation & treatment."
Treatment (specify): left blank, no treatment was specified and documented.
Risks involved: left blank, no potential or risks were documented.

I am leaving L.V. Stabler Memorial Hospital (RMCCA) at my own insistence and against the advice of my physician(s). (AMA).

Further review of the last paragraph of the document, Refusal of Treatment/Services Release From Responsibility (AMA) revealed the following documentation:

"Instructions: 1) Notify physician. 2) Document risks of leaving. 3) Have patient sign AMA form..."

PI # 1's signature was documented on the AMA form, dated 8/8/10 1938 (7:38 PM) with the witness signature, and date 8/8/19 1938 (7:38 PM).

The ED record documentation failed to include a description of the services and proposed treatment PI # 1 had refused documented on the AMA. There were no risks of leaving documented on the AMA.

There was no medical record documentation of what patient instructions, verbal and written were provided to PI # 1.

In an interview on 8/16/19 at 9:53 AM, EI # 1 confirmed the ED staff failed to complete all required AMA documentation.

4. Review of the ER Log report dated 8/8/19 revealed PI # 4 presented to the ED on 8/8/19 at 10:11 AM, chief complaint was chest wall pain, abd (abdominal) pain. The ED Log report discharge date was 8/8/19 at 11:26 AM, the discharge code, LWBS (left without being seen).

Review of PI # 4's ED presentation on 8/8/19 revealed ED registration was 10:10 AM. The ED Nursing Triage documentation completed by EI # 4, ED RN, revealed PI # 4 was triaged at the triage station at 10:36 AM. VS were documented at 10:35 AM with no abnormal values. The presenting history, "chest and top of stomach hurting, symptom onset 1 day...pain 6, location epigastric region, lower middle chest." There was no assigned Triage Level documented.

Review of the 8/8/19 10:44 AM ED Nursing Documentation physical assessment findings completed by EI # 10, ED RN, revealed a regular heart rate and rhythm, no edema, no nausea/emesis, abdomen flat, nondistended, soft, nontender, normoactive bowel sounds.

Review of the 8/8/19 11:23 AM ED Nursing Miscellaneous Nursing Note documentation completed by EI # 10, revealed "pt reports he/she doesn't want to wait any longer for available room, labs drawn upon triage (CMP [complete metabolic profile], Routine CPK [creatine phosphokinase], Routine Troponin, CBC with Diff (complete blood count/Differential) but haven't starting running yet, canceled, pt informed of risks to leaving, verbalized understanding, states he/she is leaving."

There was no documentation ED staff attempted to obtain an AMA and no documentation the patient refused to consent completing an AMA.

The medical record documentation revealed the triage was complete, however, there was no AMA completed after staff learned of the departure request, no efforts to avoid the AMA departure, no documentation the ED Physician was notified of the AMA, and no discharge instructions or follow up instructions provided.

Review of the ChartLink Physician Entered Orders included an x-ray of abdomen and chest x-ray. There was no documentation the radiology orders were complete.

In an interview on 8/16/19 at 10:03 AM, EI # 1, CNO, confirmed ED staff had completed the triage, and no AMA documentation was completed upon learning of PI # 4's desire to leave the ED.



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5. Review of the ED Summary Report dated 5/2/19 revealed PI # 9 presented to the ED on 5/2/19 at 7:22 PM, CC of Stab Wound with Electrical Wire on Right Wrist.

Review of the ED Log report revealed PI # 9's discharge date was 5/2/19 at 10:14 PM, the discharge code, L AMA.

Review of PI # 9's ED presentation on 5/2/19 revealed ED registration was 7:26 PM. EI # 6, ED RN, completed the triage at 7:48 PM. The presenting problem was documented as "Puncture wound to right medial forearm with copper wire. Patient states that he/she was working on a lawn mower and his/her arm slipped and hit the wire." Vital signs were documented as temperature: "100.1 F (Fahrenheit)", pulse "80 bpm (beats per minute)", respirations "16 breaths/min", and BP "128/92". Patient denied pain during triage. EI # 6 assessed the "Triage Level: 3 - Urgent."

Review of the Imaging Report with order date/time of 5/2/19 at 7:59 PM revealed documentation a two view x-ray right forearm was completed.

Review of the Medication Administration note revealed Tetanus, Diphtheria, Pertussis Vaccine 0.5 ml (milliliter) was administered by