HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to ensure the medical record was complete for 1 patient (#4) of 29 patients reviewed.

The findings included:

Review of a facility policy Leaving the Hospital Against Medical Advice dated 3/2/16 revealed "...steps to be taken when a patient wishes to leave the hospital without discharge orders or without the physician's approval...an adult patient capable of making his/her own decisions has the right to leave the hospital against the advice of the physician...the attending physician/designee and Clinical Director/Administrative Supervisor will be notified upon the patient's request to leave the hospital against medical advice (LAMA)...patients who leave the hospital AMA will be requested to sign a leave the hospital against medical advice (LAMA) form...if a patient refused to sign the form, the registered nurse or physician will...complete an LAMA form, indicating the patient's refusal to sign...document patient's refusal to sign in the electronic medical record (EMR)...document in the EMR pertinent observations surrounding the patient's departure and any information given to the patient...the completed LAMA form, signed or unsigned, will be placed in the patient's chart... if the patient refuses to sign the form, complete the form indicating the patient refusal to sign...document in the EMR...persons notified and the times they were notified...circumstances involved in the patient's desire to leave AMA...actions taken to effect a safe departure...complete the LAMA form...at least one witness to the signature must be a registered nurse. Place the original LAMA form in the patient's medical record..."

Medical record review revealed Patient #4 presented to the Emergency Department (ED) on 5/5/17 at 5:22 AM for complaints of chest pain and was admitted to the cardiac rehabilitation unit (CRU) at 8:03 AM.

Medical record review of a Patient Profile (visit summary) report dated 5/6/17 revealed "...Discharge Status...left against med [medical] advice [AMA]..." Continued medical record review revealed no documentation of the events leading up to the patients desire to leave AMA or of the patient's refusal to sign the AMA form. Further review revealed an AMA form was not completed by the staff.


Interview with the Risk Manager (RM) on 5/11/17 at 11:55 AM, in the conference room, revealed "...no documentation about what happened...and I would have liked to see it but unfortunately there is not any...he got angry...they called the house supervisor and she called security...he was going to leave...they offered him to sign the AMA form and he did not sign the form...he just kept escalating, slamming things around...he called his mother and she wouldn't come and get him and he got angrier after that...he was cognitively intact...typically it should be charted...the house supervisor should have documented something..."

Telephone interview with Registered Nurse (RN) #1 on 5/11/17 at 1:30 PM revealed "...His [Patient #4] heart monitor had come off so I went to check on him...he was undressed and getting into the shower and I told him he couldn't due to doctors' orders...he got a little hateful and said nobody had told him that...I asked him to get dressed and I would put his heart monitor back on...he said he was 'leaving this place as soon as the sun comes up'...he cursed...I felt very uncomfortable...I came out and told the charge nurse...I didn't feel comfortable entering the room anymore...I could hear him yelling at the charge nurse...I paged the House Supervisor..."

Telephone interview with RN #2 on 5/11/17 at 2:14 PM revealed she was the charge nurse working the night of the incident. Continued interview revealed "...His heart monitor had come off and [RN #1] had been in the room to replace it and he had been a little aggressive with her...I went in and he was upset...he wanted to take a shower...he was so upset and he said he wanted to leave...he was still yelling...we called the house supervisor and I went to get the AMA papers...he was even more aggressive at that point...we both [the house supervisor and myself] stepped out of the room until security came...his cognition was intact...he was alert and oriented...he was going to be noncompliant regardless...he was going to leave...he said he spoke to his mother..."

Interview with the Risk Manager (RM) on 5/11/17 at 2:20 PM, in the conference room, confirmed "...no documentation in the record...AMA..."

Telephone interview with Security Officer (SO) #1 on 5/11/17 at 2:30 PM revealed SO #2 walked into the patient's room and the patient was putting on his clothes and wanted to leave. Continued interview revealed "...He was complaining about the level of care, staff being rude and disrespectful...he refused to sign the AMA papers...[house supervisor] explained the AMA form to the patient...he was wanting to leave AMA..."

Telephone interview with SO #2 on 5/11/17 at 2:45 PM revealed "...as we approached you could hear [Patient #4] using inappropriate language...he was going to leave and was going AMA...[SO #1 and SO #2] tried to deescalate the situation and he told us he didn't want to hear it...[the house supervisor] tried to explain...he wasn't going to sign a [expletive] thing, he was leaving...going down the hallway he was very agitated...he was just real agitated and argumentative...he kept making unclear statements toward us as he was leaving..."

Telephone interview with House Supervisor (HS) #1 on 5/11/17 at 3:00 PM revealed she was called by the charge nurse between 5:30 AM and 6:30 AM for a patient yelling and cursing in the room. I called security and they met me there. Continued interview revealed "...he [Patient #4] was very angry...very hostile...I told him he needed to calm down...he said he had been waiting 6 hours...RN #2 was attempting to take his IV out...he was real antsy and shaky...he wanted to leave AMA...I told RN #2 I would take his IV out...he was completely unreasonable...he wasn't signing the AMA...he was so hostile and scary...no reasoning with him...I went back to the staffing office...I don't typically do that...nurse[RN #1] that had him was scared to go back into his room...I was concerned for everyone's safety...she even told the patient she was afraid of him...I left the floor...the charge nurse or primary nurse documents [incidents] and I assumed they would take care of a report...typically the primary nurse..."

Interview with Nurse Manager (NM) #1 on 5/11/17 at 3:18 PM, in the conference room, confirmed "...I talked to [Patient #4]...he was nice to me...he felt like we just didn't take care for him...my findings were that he called out and wanted some sheets then started cussing...[RN #1] felt scared and was afraid of him...he never said anything about cussing...I don't think he realized he was as agitated as he was...he said they brought the AMA papers in and he refused to sign until they took his IV out...the form should have been filled out...I would hope there would be documentation..." Further interview confirmed the medical record did not contain documentation of the events leading up to the patient leaving AMA and did not contain an AMA form. Continued interview confirmed the facility failed to follow facility policy.