HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure each patient had the right to make informed decisions regarding their care, including being able to refuse treatment.


Findings included:

Facility-based policy titled "Patient Leaving (Leaving the Floor/Against Medical Advice/Elopement)" stated in part, "Definitions:
Against Medical Advice ('AMA') - An unauthorized departure in which the patient/surrogate decision maker/ legal guardian:
1. Reviews the consequences/risks of leaving/removing the patient AMA with the patient's physician ...; or,
2. Refuses to wait to review the consequences/risks with the patient's physician ...
Procedure:
...Against Medical Advice (AMA)
1. ...the physician may inform the patient, or surrogate decision-maker, or parent/legal guardian of the potential adverse clinical consequences/risks of leaving/removing the patient from the BSWH facility AMA. If the patient, or surrogate decision-maker, or legal guardian refuses to review or wait to review the consequences/risks of leaving/removing the patient AMA, please follow these AMA procedures below.
2. The patient, or surrogate decision-maker, or parent/legal guardian may be asked to sign the Leaving Against Medical Advice Waiver and Release form. The form should be witnessed and placed/scanned in the patient's medical record.
a. If the patient, or surrogate decision-maker, or legal guardian does not sign the Leaving Against Medical Advice Waiver and Release form for any reason (e.g., refused to sign, left the facility before the form was presented), staff may follow the directions on the bottom of the form for documenting why the form was not signed, and the director, nurse manager, or administrative supervisor may be notified. The form should be witnessed by two (2) witnesses and placed in the patient's medical record.
3. Documentation may include the following elements in the patient's medical record:
...b. The potential consequences/risks of leaving/removing the patient AMA that were discussed with the patient, surrogate decision-maker, or parent/legal guardian;
...d. The patient's discharge order, noting that the patient is leaving, or being removed from the facility by the surrogate decision-maker or parent/legal guardian, AMA."

Review of the medical record for patient #1 revealed a nursing note dated 2/26/19 at 1:55 am that stated in part, " ...when another nurse said that he'd get the doctor to do the d/c [discharge] paperwork [patient #1] and [sic] yelled that [they weren't] waiting for it, [they've] had the paperwork before and knows what it said ..."
The physician note stated in part, "RN informed me that patient left the ED. [Patient #1] refused to wait to talk to me. Still had not obtained CT scans of [their] chest/abd/pelvis to rule out acute etiologies for [their] symptoms ... Patient left with a disposition of: AMA."

There was no documentation indicating potential consequences/risks of leaving discussed with the patient. There was no AMA form in patient #1's record.

Patient #11 left the emergency department AMA, the form was signed by the patient but was not witnessed by a staff member.

Patients #13 and #14 left the emergency department AMA but there was no AMA form in either record.

The above was confirmed in an interview with staff #1 and #10 on the afternoon of 6/10/19.