HospitalInspections.org

Based on clinical record review, document review and staff interviews it was revealed the Registered Nurse (RN) failed to complete a report and document patient #1 leaving the facility following hospital policy and procedures. This failure occurred in one (1) out of ten (10) clinical records reviewed. This failure has the potential to place all patients at risk for a serious adverse event.

Findings include:

1. A review of patient #1's clinical record revealed the RN failed to document in the clinical record the patient left the facility against medical advice (AMA).

2. A review of facility policy, "Patient Leaving Hospital Against Medical Advice/Elopements, PCM-SPP-0004," effective 01/2020, states in part: "Inpatient Units: ... Document in nurse's notes, the reason the patient/responsible individual gives for leaving and the instructions he/she was given. Note the condition of the patient/responsible individual and his objective mental and physical status. Complete an (occurrence) report."

3. A review of the facility's occurrence log from 05/01/21 through 06/28/21 revealed a report of patient #1 leaving AMA was not reported.

4. An interview was conducted on 06/30/21 at approximately 11:55 a.m. with the Director of Risk Management and Patient Safety. When asked if a report was completed of patient #1 leaving AMA, he verbalized there was none.

5. An interview was conducted on 06/30/21 at approximately 12:15 p.m. with the Assistant Chief Nursing Officer (ACNO) and Nurse Manager #1. When notified there was not any nursing note in patient #1's clinical record of the patient leaving AMA following facility policy, they concurred there was not a nursing note documenting the patient left AMA.