HospitalInspections.org

Based on policy review, medical record reviews, and staff interview, it was determined the facility failed to provide services and honor patient rights of transfer and discharge against medical advice (AMA) for three (#1, #2, #5) of six patient medical records sampled.

Findings included:

A review of the policy entitled, Against Medical Advice (AMA) Discharge, no #, revised 08/06/20, showed:
1. The nursing unit staff will notify the physician of the patient's intent to leave AMA, and of actual elopement.
2. The physician must decide that the patient is:
a. Alert and Oriented to time, person , and place.
b. Not mentally impaired due to alcohol, drugs, or other recognizable organic factors or mental illness.
c. Fully aware of provisional diagnosis.
d. Aware of the risk (s) related to refusing treatment...
3. The RN must notify the physician (primary and consultations) of the discharge...
4. Check for instructions the physician may wish to give.

A review of Patient #1's physician history and physical (H&P) documentation dated 09/08/20 at 7:24 AM showed the patient was admitted on 09/07/20 for the following: a thrombus (clot) in the abdominal aorta (as see on cat scan), sepsis, bacteremia (bloodstream infection), bilateral lower extremity weakness, influenza, low magnesium, thrombocytopenia (low platelets), anemia, and hypertension.

On 09/08/20 at 2:24 PM, the cardiothoracic surgeon documented Patient #1 wished to be treated at hospital X.

On 09/08/20 at 6:38 PM, nursing documentation showed Patient #1 stated he would like to be transferred to hospital X. The note showed the cardiothoracic surgeon and primary care physician were aware of the patient and family's wishes to be treated at hospital X. The nursing note at 9:20 PM showed the patient left AMA and that the physicians had declined to accommodate the patient/family requests for transfer, as it was not necessary to patient care.

On 09/08/20 at 4:30 PM a bilateral extremity arterial study resulted and showed severe peripheral vascular diseases (PVD) of the left leg and femoral artery, suggesting inflow stenosis, probable hemodynamically significant stenosis at the origin of the left profunda.

On 09/08/20, the physician DC summary showed the patient was instructed to follow any DC instructions given, take any medications prescribed, and resume care as soon as possible with another provider.

On 10/21/20 at 11:45 AM, an interview with the VP of Quality, confirmed the facility failed to honor the patient's right of transfer and the physician, after being notified by nursing, failed to write a DC order. The VP stated that the DC order provides nursing with DC instructions for the patient that includes; the patient's diagnosis, treatments, testing and information pertaining to the patient ' s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge. The VP confirmed there was no evidence the patient was provided DC instructions to include the results of the bilateral extremity arterial study prior to leaving.

A review of Patient #2's emergency department (ED) physician history and physical (H&P) documentation dated 08/01/20 at 11:30 AM, showed the patient presented to the ED with complaints of nausea, vomiting (N/V), epigastric pain, and diarrhea. The noted showed the patient had also been seen at the facility on 07/29/20 and 07/30/20, with reports of the same symptoms; nausea, vomiting and epigastric pain. The patient was admitted for further tests and treatment of abdominal pain and pancreatitis.

A review of Patient #2's inpatient physician H&P documentation dated 08/01/20 at 4:47 PM, also showed a diagnosis of N/V, and treatment for pancreatitis. The physician ordered a cat scan (CT) to rule out pancreatitis and if negative, they would consult a gastrointestinal (GI) physician for an endoscopic retrograde cholangiopancreatography (ERCP).

A review of Patient #5's physician H&P dated 09/10/20 at 2:49 AM, showed a 71 year that presented to the facility with complaints of chest pain (CP). The pain was accompanied by nausea, dizziness and some shortness of breath. At 10:34 AM the physician note revealed the cat scan (CT) of the chest showed a small left side pleural effusion and echocardiogram testing was pending results. At 1:49 PM, the physician note showed the patient left AMA.

On 10/21/20 at 1:30 PM, an interview with the VP of Quality, revealed Patient #2 left the facility AMA at 9:59 PM. The VP confirmed nursing failed to notify the physician that the patient left AMA and there was no physician documentation present showing the patient had been made fully aware of the provisional diagnosis and of the risk (s) related to refusing treatment. The VP confirmed there was no further nursing or physician documentation in Patient #5's medical record regarding why the patient left AMA, or whether made fully aware of the provisional diagnosis, and risk (s) related to refusing treatment.