HospitalInspections.org

Based on an review of medical records including restraint records and policy review, it is revealed that the hospital administered treatment to patient #1 who had expressly refused that treatment.

Review of the hospital policy "Consent/Refusal to Consent" effective. December 2014 states in part, "Disabled individual" means an individual who lacks sufficient understanding or capacity to make or communicate a responsible decision on healthcare as determined by physicians in accordance with section I.J. of this policy because of: A physical disability; Chronic alcoholism; Drug addiction; A disease; or, Mental disability including senility." The policy continues under part I.J., "The substitute consent may be given only if two physicians, after attempting to consult with the patient regarding the proposed healthcare, certify in writing that the patient is incapable of making an informed decision ..."

Review of the records for patient #1 revealed that patient #1 is an adult male who presented to the emergency department (ED) on October 23, 2014 via ambulance following a complaint of arm pain. While in the ED, he was found to be acutely psychotic and was admitted to a medical floor of the hospital since the hospital has no psychiatric unit. He was treated with antipsychotic medication.

A nursing note of 0442 on the day of admission reveals in part, "...Patient is refusing to have IV inserted and labs drawn ....after multiple request from patient to have blood drawn, patient finally allowed staff to put an IV in and draw blood."

Patient #1, who was capable of making his own decisions, was assessed as needing involuntary commitment. Involuntary documentation was completed and patient #1 remained on a medical unit awaiting acceptance and transfer to a hospital with an inpatient psychiatric unit. During admission, patient #1 refused multiple medical interventions including vitals, and medication, though he did take medication at times. However, patient #1 primarily refused the placement of, or the retaining of IVs which had been placed.

On the day of admission at 0935, an RN wrote "While attempting to get OOB (Transferred to bed from a stretcher) patient requested to have his left arm IV ( intravenous) removed as it was making him feel dizzy ...Patient also explained that IVF ( intraveneous fluids) being infused was needed for hydration. Patient expressed understanding."

At 1240, the RN wrote "patient got out of bed and stated, 'it's time to go.' Patient very anxious and agitated also said he wanted his "IV to come out." IV tube disconnected from pt." This means that the IV was left in his arm but capped off for future use. At 1524 the RN wrote "Attempt to dislodge his left arm IV access. All attempts to discourage him from doing so were unsuccessful. " On the third day of admission at 1630, the RN documented in part, "pt pulling at IV line stated wants it out. Disconnected IV so pt could void. Pt refused to have IV reconnected."

Patient #1 continued with multiple refusals and infrequent compliance throughout the admission. Additionally, he was alternately restrained for periodic attempts to leave the hospital while under involuntary commitment and infrequent combativeness when staff attempted to stop him from leaving. It was noted that his creatinine phosphokinase (CPK) was elevated. CPK is an enzyme found in brain, skeletal and heart muscle and tissue which when elevated, indicates a break-down of muscle tissue somewhere in the body. His elevated CPK prevented medical clearance for discharge to a psychiatric inpatient setting. A treatment for this condition is to give IV fluids to dilute and aid excretion.

On the fifth day of admission at 1449, an RN documented "Assumed care of pt this am, alert, delusional, and inappropriate, resistive to care, gets combative, hostile and angry, insisted that he wants his clothes so he can leave. Refuse IV start and medication and was trying to leave. Pt repeatedly told he cannot leave until he is discharged by the doctor but he will not listen. Security called and IV place in left arm, secured by cling gauze, IVF NS (normal saline) started, pt given Ativan x 2 and Haldol IM ( intramuscular) also."

Based on this documentation, the hospital placed an IV against the expressed refusal of patient #1 who was considered capable of refusing that treatment until deemed otherwise according to hospital policy. Because the hospital failed to certify that patient #1 was incompetent to make his own decisions, they were obligated to respect patient #1's right to refuse.

A psychiatric consult was performed on October 27, 2014 which found patient #1 to be oriented to time, place and person, with a well-organized thought process, and not an imminent danger to self or others. The psychiatrist recommended a voluntary inpatient admission for marked paranoid and persecutory delusions. However, patient #1 was not willing and he was discharged from the hospital "Against Medical Advice."