The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 June 23, 2015
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility policy review, medical record review, and interview, the facility failed to follow its policy on completion of Leaving Against Medical Advice (AMA) and failed to complete nursing documentation to support patient response to services for 1 (#5) of 10 patients reviewed.

The findings included:

Review of the policy entitled "Leaving Against Medical Advice", # 27, revised 10/2014, revealed "...PROCEDURE: 2. If at all possible the Attending Physician should speak to the patient in person or by phone to determine why the patient wishes to leave. 4. The physician must attempt to advise the patient of the risks or complications that could occur from leaving AMA. This should be done in the presence of a family member if possible. 5. The physician and staff member must document in the medical record: a. patient's desire to leave AMA; b. the patient has the capacity to make medical decisions; c. the extent of the discussion with the patient regarding the risks and benefits of leaving AMA. 7. The patient is requested to sign an AMA form. If the patient refuses, staff must document this on the form..."

Medical record review revealed Patient #5 was admitted to the facility on [DATE] with diagnoses of [DIAGNOSES REDACTED]], Chronic Obstructive Pulmonary Disease, Gastroesophageal Reflux Disease, Atherosclerotic Cardiovascular Disease, and Cocaine Abuse.

Medical record review of the History and Physical (H&P) dated 1/10/15 revealed Patient #5 was complaining of palpitations and indigestion on presentation to the Emergency Department on Friday 1/10/15. Continued review of the H&P revealed Patient #5 occasionally had chest pressure over the lower part of his chest which was non-radiating and felt like a squeezing sensation. Further review of the H&P revealed Patient #5 had not taken his cardiac medications for the last month. Continued review of the H&P revealed the plan was to admit the patient to an intensive care unit and to have a stress test on Monday 1/12/15.

Medical record review of the cardiology consultation dated 1/10/15 revealed a stress test was scheduled for Monday 1/12/15, and if it was positive, the physicians would proceed to coronary angiography. Continued medical record review revealed if the patient's left ventricular ejection fraction (indicator of heart function) was less than 35%, then consideration would be given to insertion of a pacemaker defibrillator.

Medical record review of an Internal Medicine progress note dated 1/12/15 at 10:25 AM, revealed "...Pt (patient) verbally abusive to nursing staff and physician. Keeps changing his mind regarding whether or not he wants a stress test. Voiced that if he was not willing to have an arteriogram or bypass that the stress test would be of minimal value. Pt. upset that he 'can't get stress test'. Voiced that he was on the schedule for the stress test then he voiced that he didn't want the stress and that he just wanted to eat and just wanted to get his prescriptions. This morning he wants to leave AMA (against medical advice) but would not sign the papers..."

Medical record review of the Discharge Summary dated 1/13/15 revealed, "...The patient (#5) was seen by Cardiology and the patient had a planned stress test today on 1/12/15. The patient was being verbally abusive to the staff including the nurses and Cardiology was notified of this and given the patient had decided that he did not want anything done even if the stress test was positive including cardiac cath or any other procedures, Cardiology canceled the stress test and the patient decided to leave against medical advice..."

Medical record review revealed there was no AMA form in the record and no documentation in narrative nursing notes of the verbally abusive behavior.

Interview with the Director of Nursing (DON) on 6/22/15 at 3:00 PM, in the conference room, confirmed the AMA form was not present in the medical record. Further interview confirmed the AMA form was to be in the medical record, signed by nurses, and a statement the patient refused to sign the form. Continued interview with the DON confirmed there was no nursing narrative documentation in the record of Patient #5 regarding his behavior and his refusal to sign the AMA form.