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Based on review of the facility compliance manual, medical record review, review of a patient recall/follow up document, review of Emergency Department (ED) rounding notes, review of video surveillance footage, and interviews, the facility failed to document the risks of leaving against medical advice (AMA) for 1 Emergency Department (ED) patient (Patient #1) with a cutaneous abscess (painful collection of pus) of 30 ED patients reviewed.

The findings include:

Medical record review showed Patient #1 presented to the ED on 6/11/2021 with complaint of an abscess to the right axilla (armpit), which had gotten worse over the past 2 or 3 days. The abscess was drained and sent for cultures. The patient was given Tramadol (pain medication) and Clindamycin (antibiotic) intramuscular while in the ED. The patient was given a prescription for Clindamycin to take every 6 hours for 10 days and was discharged home the same day. On 6/13/2021 at 11:24 AM Patient #1 returned to the ED for possible intravenous antibiotics because the wound culture obtained on 6/11/2021 was positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Patient #1 was triaged at 12:01 PM and had a medical screening exam at 12:07 PM. The patient returned to the ED lobby after the screening exam to wait for an available ED bed. Patient #1 became upset due to the long wait in the ED lobby and left against medical advice (AMA) at 4:14 PM. Medical record review showed no documentation to indicate the risks of leaving AMA were explained to Patient #1.

Please refer to A-2407 Refusal to Consent to Treatment.

Based on review of the facility compliance manual, medical record review, review of video surveillance footage, and interviews, the facility failed to document the risks of leaving against medical advice (AMA) for 1 Emergency Department (ED) patient (Patient #1) with cutaneous abscess (painful collection of pus) of 30 ED patients reviewed.

The findings include:

Review of the facility's Compliance Manual revised 6/2020 showed "...if the hospital determines that an emergency medical condition exists, it must either provide the treatment necessary to stabilize the emergency medical condition...A hospital is considered to have met this second requirement if an individual refuses the hospital's offer of additional examination or treatment...after having been informed of the risks and benefits..."

Medical record review showed Patient #1 presented to the ED on 6/11/2021 with complaint of an abscess to the right axilla (armpit) which had gotten worse over the past 2 or 3 days. The abscess was drained and cultured, Clindamycin (antibiotic) was given intramuscular while in the ED. A prescription for Clindamycin by mouth every 6 hours for 10 days was provided. Patient #1 was discharged to home the same day.

Medical record review of an ED Patient Recall and Follow-up form showed Patient #1 had been notified the wound culture from 6/11/2021 was positive for Methicillin Resistant Staphylococcus Aureus (MRSA- an infection) on 6/13/2021 at 10:10 AM. The patient was notified the current antibiotics would not treat the infection and was instructed to return to the ED for possible intravenous (IV) antibiotics.

Medical record review showed Patient #1 presented to the ED on 6/13/2021 at 11:24 AM.

Medical record review of an ED Triage Provider Note dated 6/13/2021 at 12:07 PM showed Patient #1 had been called to come back to the ER because "...her blood cultures were positive. Susceptible to vancomycin...This was a provider in triage/medical screening examination. My examination provides an initiation of medical screening exam with preliminary orders placed to initiate and facilitate care of patient...Orders placed will be assumed by downstream Emergency Department provider..."

Medical record review of Care Giver Rounding notes for 6/13/2021 showed the nursing team leader went to the lobby to speak with Patient #1 at 4:11 PM at the patient's request. Patient #1 and the patient's spouse were upset because of the long wait for further evaluation and treatment. Patient #1 and the patient's spouse left the ED at 4:14 PM (4 hours 50 minutes after arrival) Continued review showed no documentation to indicate the risks of leaving the facility AMA were explained to Patient #1.

Medical record review showed an AMA form was not in Patient #1's medical record.

Review of facility surveillance video recording for 6/13/2021 from 11:00 AM-3:51 PM showed the following: (Please note some of the video surveillance times are different from documentation times).
11:24 AM-Patient #1 and the patient's spouse entered the ED.
11:32 AM-Patient #1 and the patient's spouse presented to triage intake desk (located in the ED lobby).
12:01 PM-Patient #1 and the patient's spouse entered a triage room.
12:10 PM-Patient #1 and the patient's spouse exited a triage room and took a seat in the ED lobby.
3:14 PM- Patient #1 walked to right side of triage desk and spoke to a staff member.
3:42 PM- Patient #1's spouse approached the triage desk and spoke with a staff member (approximately 30 seconds).
3:45 PM- The ED team leader entered the ED lobby, spoke with a staff member at the desk and then approached the area
where Patient #1 and the patient's spouse were seated.
3:50 PM- Patient #1 and the patient's spouse exited the ED. The team leader walked to the ED entrance and observed Patient
#1 and the patient's spouse as they left the ED.

During a telephone interview on 6/16/2021 at 9:20 AM, Patient #1 confirmed she went to the ED on 6/11/2021 for an abscess under her right arm. Patient #1 reported the abscess was drained and wound cultures were performed during this ED encounter. Patient #1 was discharged with a prescription for antibiotics on the same day. Patient #1 was notified she needed to return to the ED on 6/13/2021 for possible IV antibiotics because the cultures (wound) were positive for MRSA. The patient was told to be prepared to be admitted. The patient stated "...Apparently my bed was given away..." because they waited in the ED lobby for 4.5 hours. After 1 hour 10 minutes, they were told it would be another 1.5 hours; 1.5 hours later they were "...told the same thing [1.5 hours]..." After 4.5 hours, Patient #1's spouse asked to speak with the person in charge. After they had spoken with the ED Team Leader, Patient #1 stated she (Patient #1) "...walked out...went home...took meds...and antibiotics..." she had been given on her first visit to the ED on 6/11/2021.

During a telephone interview on 6/18/2021 at 11:00 AM, the ED Team Leader stated Patient #1 was upset because she had been waiting so long in the ED lobby. The ED Team leader stated she had someone call security because Patient #1 and patient's spouse were so upset. The ED Team Leader stated Patient #1 and the patient's spouse left the ED before the patient received further evaluation and treatment. The ED Team Leader did not indicate she had explained the risks of leaving the ED AMA to
Patient #1.