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Based on the review of 32 medical records it was determined that one patient was not informed of the riskd and benefits of leaving the ED without being seen and receiving treatment.
Patient # 30 is a [AGE] year old female who was transported by Emergency Medical ambulance to the Franklin Square Hospital Emergency Department on September 14, 2011 at 9:08 am after having sustained a fall with right flank pain. At the time of her initial ED visit Patient #1 received a triage assessment which included a pain assessment. Patient #1 rated her pain level at 10 on a scale of 0-no pain to 10 being severe.
A full nursing assessment and a medical examination by the physician were completed. Diagnostic studies were also completed and patient #1 was medicated with Dilaudid 1 milligram for pain. Dilaudid is an opioid analgesic used to treat moderate-to-severe pain. Patient #30 was also administered two doses of Zofran 4 milligrams each for nausea and vomiting. At 2:59 pm patient #1 was provided discharge instructions and discharged to home accompanied by family.
However, at 4:48 pm patient #30 returned to the ED via 911 emergency services with complaints of vomiting and diarrhea. At that time a triage assessment was initiated by the triage nurse. Vital signs were obtained and Patient #30 stated that she had been at the hospital earlier and was overdosed with Morphine. Patient #30 also complained of pain at a level of 10. However, there is no documentation that patient #30 was administered any analgesic other than the Dilaudid during her earlier visit to the ED.
On further review of the medical record, there is no documentation of a full nursing assessment or a medical screening examination being initiated. There is an extended triage note written at 5:30 pm that states that Patient #30 was being belligerent to staff and that Patient #1 stated that she was lying on the triage room floor "when she was "man handled" by the triage nurses who made her stand up on her own instead of picking her up off of the floor.
Further review of the nursing note indicates that Patient #30 requested to speak with the charge nurse at which time the triage nurse went into the room. The nursing note states that Patient #30 informed the nurse that she had soiled herself, then hopped off the stretcher, and stated she was leaving. The note also indicates that at that time the nurse discontinued the intravenous access from Patient #30's left hand and provided her linens to clean herself. The nurse further documented that Patient #30 was verbally aggressive at which time security was asked to be available. However, there is no documentation that at that time the nurse made the physician aware that Patient #30 was leaving the ED without being examined.
Based on review of the hospital's policy Emergency Medical Condition Evaluation, Treatment, and Transfer (EMTALA) Section 3, under 3.1. it states " If the patient refuses to consent to examination, treatment, or transfer, the Hospital should take all reasonable steps to have the patient (or the patient's legally responsible person) sign a written refusal to consent such as an Against Medical Advice (AMA) form, which indicates that the patient has been informed of the benefits and risk of examination, treatment, and or transfer and the reason for refusal. However, there is no indication that the nurse, physician, or any other staff provided Patient #30 with the AMA form.
On further review of the hospital's policy, specifically, Section 3.2, the policy indicates that the AMA form must be made a part of the medical record and if the patient is unwilling to sign the AMA form after reasonable efforts by hospital staff, documentation of the patient's refusal should be included in the medical record. However, there was no AMA form found in the medical record of Patient #30 nor was there documentation that the hospital had taken all reasonable steps to secure the refusal in writing.