HospitalInspections.org

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Based on observations, review of documents, and staff interviews, the facility failed to ensure the policies and procedures governing medical care provided in emergency service were established by and continuing responsibility of the medical staff when the facility's Emergency Department (ED) failed to follow its policy titled, "Informed Refusal, Against Medical Advice (AMA), Absent Without Leave," Reference #982, Version 7, on 08/15/2024 at 3:10 pm for one of 20 patients whose records were reviewed. The policy outlined that a medical provider should complete a Medical Screening Exam (MSE) before the patient leaves AMA, the facility staff should make every effort to persuade the patient to stay, the facility staff should document those efforts in the patient record, and the facility staff should attempt to contact the patient following departure with any necessary follow-up care as deemed necessary by the provider.
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Findings were:
Medical Record Review at Facility A
On 08/15/2024, at 2:50 PM, Patient #1, a 34-year-old female, arrived at the emergency department (ED) of Facility A with chief complaints of chest and back pain, shortness of breath (SOB), nausea, and vomiting on 08/15/2024. Patient #1 was recently discharged from hospital on 08/14/2024. Patient #1 was recently discharged from hospital on 08/14/2024.
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The triage nurse, Staff #5, assigned a priority of "3 Urgent" (meaning Patient #1 had a situation requiring medical attention and action without being considered life-threatening or immediately critical) to Patient #1 at 2:55 PM on 08/15/2024. Vital signs were obtained, noting a pulse rate of 104. The triage nurse, Staff #5, documented that Patient #1 " ...saw care coordination and she helped her set up an appointment with her doctor for tomorrow ..."
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The hospital care coordinator saw that Patient #1 had several ED visits and called Patient #1's primary care provider (PCP) and made Patient #1 an appointment for the next day. Patient #1 was informed that an appointment was made for her with her PCP. Patient #1 decided to leave and was told she had to sign an AMA form. Patient #1 was not seen by a medical provider for an medical screening examination (MSE) to determine if she had a medical emergency condition related to her chest and back pain, nausea, vomiting and shortness of breath.
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At 3:10 PM on 08/15/2024, an Against Medical Advice (AMA) form was provided to Patient #1 and she signed it, however, there was no review of the risks of leaving without being seen and no medical advice was given to Patient #1.
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Document Review:
A review of the document titled "Patient Refusal/AMA Form" signed by Patient #1 found in Patient #1's medical record on 08/15/2024 at 3:10 PM revealed, "Requires Physician or Advance Practice Provider (APP) certification on pg. 2". The following portions of the required physician or APP certification were left blank on pg. 2: ..." but the document was not signed by a physician/mid-level practitioner.
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The document titled, "Patient Refusal/AMA Form" requires that "Risks" (to include worsening of the condition, loss of limb, death and/or permanent disability, or other) and "Benefits" (to include determining the diagnosis, improved outcome, specialty care (diagnostic, medicine, personnel), and other), to be checked off by the physician. These sections were blank.
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At 3:14 PM on 08/15/2024, a note was entered by Staff #2 (Care Coordinator) stating the following:
"f/u (follow up) appointment with family practice tomorrow at 9:15 (AM). Reviewed with patient and she left from the ER."
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Policy Review:
The facility's policy titled, "Informed Refusal, Against Medical Advice, Absent Without Leave", Reference #982, Version 7, stated on page 1 of 3:
" ...A. If and when a patient requests to, or states that s/he will leave the hospital Against Medical Advice (AMA), every effort will be made by staff in a safe manner, to persuade the patient to remain and receive care. If efforts are not successful, additional attempts will be made to convince the patient to remain until the LIP (licensed independent provider) is contacted or arrives. Emphasize to patient that they are welcome to return for care or have recommended care at a later time ..."
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And:
" ...D. All patients who leave AMA will be requested to sign a Release Against Medical Advice form (SPF 529-19). The patient should be given discharge instructions despite the fact that they choose to leave AMA ..."
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And:
" ...I. In the emergency department:
1. If a patient leaves and there are still pending studies, the patient will be left on the ED tracker until the LIP has reviewed the test results for any abnormal findings. Should there be an abnormal finding, the nursing staff or ED Unit Clerk will attempt to contact patient once so that the LIP can discuss the abnormal results with the patient. This attempt will be documented in the patient record. If the patient is unable to be contacted, a letter will be sent to the patient informing them of the abnormal results and any follow- up care deemed necessary by the LIP ..."
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And on page 2 of 3:
" ...3. If a patient leaves the Emergency Department without seeing a practitioner, the nursing staff will discharge the patient in the computer as LWOB (Left Without Being Seen). If a staff member makes contact with the patient who is wanting to leave without being seen in the staff member should encourage the patient to stay for evaluation and treatment. If the patient still desires to leave without being seen, the staff member will document the reason that the patient states they are leaving in the patient record. Should the patient leave without staff awareness, the staff member will attempt to contact the patient by telephone before the end of the shift. If contacted, patient will be encouraged to return for re-evaluation and possible treatment. If not contacted, the staff member will attempt to leave a voicemail if available. Calls, and the results of the attempted patient contact, will be documented in the patient record. If the patient states that they will return to the emergency department for evaluation, the Emergency Registration staff will be notified and will attempt to expedite the patient's reception process; the patient will be recepted into the ED again ..."
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These portions of the facility's policy were not followed for Patient #1.
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Interviews:
An interview with the Care Coordinator, Staff #2, took place on 10/08/2024, at 2:30 PM. Staff #2 indicated that if there are multiple visits noted, she would speak with the patient, find out if they had a follow-up visit from their last (emergency department) ED encounter, and she would contact the (primary care provider) PCP to find out if patient made follow-up visit. If the patient had not, she would make the appointment for them. Staff #2 confirmed that Patient #1 was not seen by a physician/mid-level provider or her nurse again before leaving the facility.
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An interview with the second triage nurse, Staff #7, for Patient #1 took place on 10/08/2024, at 4:00 PM. Staff #7 was asked to explain the process for a patient leaving against medical advice (AMA). Staff #7 indicated that when a patient wants to leave AMA, the nurse is to inform the physician/mid-level provider. The physician/mid-level provider asks patient why they want to leave AMA and goes over the risks/benefits of not being seen by a provider. If the patient still wants to leave, will have them complete and sign the AMA form. Staff #7 could not recall if or why Patient #1 left without being seen and could not locate within the medical record that this had been done for Patient #1.
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During the interview with Staff #7, the Director of the Emergency Department (ED), Staff #4, indicated that if a patient who was registered at the ED and left without being seen, a follow-up phone call should be made to the patient and the patient should be encouraged to return to the ED for a Medical Screening Examination (MSE), to ensure there is no life-threatening emergency.
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An interview with the Quality Services Director, Staff #1 took place on 10/19/2024 at 5:53 PM.
Staff #1 was asked clarifying questions following the interview with Staff #2. Staff #1 indicated that a position was added for an ED RN Case manager position. The position was created to assist with patient placement from the ED, including transfers, and to assist patients with obtaining follow up appointments with their PCP and/or needed specialty physician care appointments, but it was not meant to prevent patients from being seen for an MSE (medical screening examination).
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Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.
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Based on record review and interview, the facility failed to provide an emergency medical screening examination for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the emergency department (ED) at Facility A with complaints of chest pain, shortness of breath (SOB), and fever on 08/15/2024. Patient #1's medical history was reviewed upon registering to the Emergency Department and it was determined that Patient #1 was recently treated at the facility on 8/12/2024 for acute dehydration, tachycardia, abdominal pain, constipation, and pancreatitis. Patient #1 was discharged from the hospital on 08/14/2024. The discharge diagnosis was noted as constipation, abdominal pain, vomiting, tachycardia, anxiety, and depression. A PCP (primary care physician)) appointment was made Patient #1 and Patient #1 signed out AMA (against medical advice) without the form being completed by a physician/mid-level practitioner or receiving a medical screening exam by a qualified medical professional.
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Cross Reference to:
Tag A-2406 - 42 CFR §489.24 (a) (c) Appropriate Screening Examination.
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Based on record review and interview, the facility failed to provide an emergency medical screening examination for one of 20 (Patient #1) patients whose records were reviewed. Patient #1 presented to the emergency department (ED) at Facility A with complaints of chest pain, shortness of breath (SOB), and fever on 08/15/2024. Patient #1's medical history was reviewed upon registering to the Emergency Department and it was determined that Patient #1 was recently treated at the facility on 8/12/2024 for acute dehydration, tachycardia, abdominal pain, constipation, and pancreatitis. Patient #1 was discharged from the hospital on 08/14/2024. The discharge diagnosis was noted as constipation, abdominal pain, vomiting, tachycardia, anxiety, and depression. A PCP (primary care physician)) appointment was made Patient #1 and Patient #1 signed out AMA (against medical advice) without the form being completed by a physician/mid-level practitioner or receiving a medical screening exam by a qualified medical professional.
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Findings include:
Medical Record Review at Facility A
On 08/15/2024, at 2:50 PM, Patient #1, a 34-year-old female, arrived at the emergency department (ED) of Facility A with chief complaints of chest and back pain, shortness of breath (SOB), nausea, and vomiting on 08/15/2024. Patient #1 was recently discharged from hospital on 08/14/2024. Patient #1 was recently discharged from hospital on 08/14/2024.
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The triage nurse, Staff #5, assigned a priority of "3 Urgent" (meaning Patient #1 had a situation requiring medical attention and action without being considered life-threatening or immediately critical) to Patient #1 at 2:55 PM on 08/15/2024. Vital signs were obtained, noting a pulse rate of 104. The triage nurse, Staff #5, documented that Patient #1 " ...saw care coordination and she helped her set up an appointment with her doctor for tomorrow ..."
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The hospital care coordinator saw that Patient #1 had several ED visits and called Patient #1's primary care provider (PCP) and made Patient #1 an appointment for the next day. Patient #1 was informed that an appointment was made for her with her PCP. Patient #1 decided to leave and was told she had to sign an AMA form. Patient #1 was not seen by a medical provider for an medical screening examination (MSE) to determine if she had a medical emergency condition related to her chest and back pain, nausea, vomiting and shortness of breath.
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At 3:10 PM on 08/15/2024, an Against Medical Advice (AMA) form was provided to Patient #1 and she signed it, however, there was no review of the risks of leaving without being seen and no medical advice was given to Patient #1.
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A review of the document titled "Patient Refusal/AMA Form" signed by Patient #1 found in Patient #1's medical record on 08/15/2024 at 3:10 PM revealed, "Requires Physician or Advance Practice Provider (APP) certification on pg. 2". The following portions of the required physician or APP certification were left blank on pg. 2: ..." but the document was not signed by a physician/mid-level practitioner.
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The document titled, "Patient Refusal/AMA Form" requires that "Risks" (to include worsening of the condition, loss of limb, death and/or permanent disability, or other) and "Benefits"(to include determining the diagnosis, improved outcome, specialty care (diagnostic, medicine, personnel), and other), to be checked off by the physician. These sections were blank.
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At 3:14 PM on 08/15/2024, a note was entered by Staff #2 (Care Coordinator) stating the following:
"f/u (follow up) appointment with family practice tomorrow at 9:15 (AM). Reviewed with patient and she left from the ER."
.
Policy Review:
The facility's policy titled, "Informed Refusal, Against Medical Advice, Absent Without Leave", Reference #982, Version 7, stated on page 1 of 3:
" ...A. If and when a patient requests to, or states that s/he will leave the hospital Against Medical Advice (AMA), every effort will be made by staff in a safe manner, to persuade the patient to remain and receive care. If efforts are not successful, additional attempts will be made to convince the patient to remain until the LIP (licensed independent provider) is contacted or arrives. Emphasize to patient that they are welcome to return for care or have recommended care at a later time ..."
.
And:
" ...D. All patients who leave AMA will be requested to sign a Release Against Medical Advice form (SPF 529-19). The patient should be given discharge instructions despite the fact that they choose to leave AMA ..."
.
And:
" ...I. In the emergency department:
1. If a patient leaves and there are still pending studies, the patient will be left on the ED tracker until the LIP has reviewed the test results for any abnormal findings. Should there be an abnormal finding, the nursing staff or ED Unit Clerk will attempt to contact patient once so that the LIP can discuss the abnormal results with the patient. This attempt will be documented in the patient record. If the patient is unable to be contacted, a letter will be sent to the patient informing them of the abnormal results and any follow- up care deemed necessary by the LIP ..."
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And on page 2 of 3:
" ...3. If a patient leaves the Emergency Department without seeing a practitioner, the nursing staff will discharge the patient in the computer as LWOB (Left Without Being Seen). If a staff member makes contact with the patient who is wanting to leave without being seen in the staff member should encourage the patient to stay for evaluation and treatment. If the patient still desires to leave without being seen, the staff member will document the reason that the patient states they are leaving in the patient record. Should the patient leave without staff awareness, the staff member will attempt to contact the patient by telephone before the end of the shift. If contacted, patient will be encouraged to return for re-evaluation and possible treatment. If not contacted, the staff member will attempt to leave a voicemail if available. Calls, and the results of the attempted patient contact, will be documented in the patient record. If the patient states that they will return to the emergency department for evaluation, the Emergency Registration staff will be notified and will attempt to expedite the patient's reception process; the patient will be recepted into the ED again ..."
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These portions of the facility's policy were not followed for Patient #1.
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Interviews:
An interview with the Care Coordinator, Staff #2, took place on 10/08/2024, at 2:30 PM. Staff #2 indicated that if there are multiple visits noted, she would speak with the patient, find out if they had a follow-up visit from their last (emergency department) ED encounter, and she would contact the (primary care provider) PCP to find out if patient made follow-up visit. If the patient had not, she would make the appointment for them. Staff #2 confirmed that Patient #1 was not seen by a physician/mid-level provider or her nurse again before leaving the facility.
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An interview with the second triage nurse, Staff #7, for Patient #1 took place on 10/08/2024, at 4:00 PM. Staff #7 was asked to explain the process for a patient leaving against medical advice (AMA). Staff #7 indicated that when a patient wants to leave AMA, the nurse is to inform the physician/mid-level provider. The physician/mid-level provider asks patient why they want to leave AMA and goes over the risks/benefits of not being seen by a provider. If the patient still wants to leave, will have them complete and sign the AMA form. Staff #7 could not recall if or why Patient #1 left without being seen and could not locate within the medical record that this had been done for Patient #1.
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During the interview with Staff #7, the Director of the Emergency Department (ED), Staff #4, indicated that if a patient who was registered at the ED and left without being seen, a follow-up phone call should be made to the patient and the patient should be encouraged to return to the ED for a Medical Screening Examination (MSE), to ensure there is no life-threatening emergency.
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An interview with the Quality Services Director, Staff #1 took place on 10/19/2024 at 5:53 PM.
Staff #1 was asked clarifying questions following the interview with Staff #2. Staff #1 indicated that a position was added for an ED RN Case manager position. The position was created to assist with patient placement from the ED, including transfers, and to assist patients with obtaining follow up appointments with their PCP and/or needed specialty physician care appointments, but it was not meant to prevent patients from being seen for an MSE (medical screening examination).
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