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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 July 15, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on record review and interview, the facility failed to ensure that the appropriate documentation was completed per the facility's policy for 1 of 4 patients (Patient # 3) who left against medical advice in a total sample of 23 Emergency Department medical records reviewed.

Findings include:

The facility failed to complete the appropriate documentation for 1 of 4 patients who left the Emergency Department against medical advice. See Tag A-2407.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on record review and interview, the facility failed to ensure that the appropriate documentation was completed per the facility's policy for 1 of 4 patients (Patient #3) who left against medical advice (AMA) in a total universe of 23 Emergency Department medical records reviewed.

Findings include:

Review of the facility policy # 79 titled, "Patients Leaving Against Medical Advice/Elopement, AW" last revised 2/2019 revealed, "...DEFINITIONS...AMA - Against Medical Advice...PROCEDURE...DOCUMENTATION REQUIREMENTS FOR ALL AMA (Against Medical Advice) DEPARTURES AND ELOPEMENTS 1. All information relating to the patient's AMA discharge shall be gathered and documented in the patient's health record, including but not limited to: a. The patient's verbatim statement about why he or she wants to leave against medical advice (AMA). b. Contact or attempts to contact the Physician. c. Risks disclosed to the patient. d. Discharge teaching and prepared materials, prescriptions and alternative options (home care, Outpatient treatment...) given to the patient. e. The Physician should also document the status of the patient's decision-making capacity...COMPETENT ADULT PATIENT(S) LEAVING AGAINST MEDICAL ADVICE...3. Complete the AMA form used by the facility where the patient is being treated. 4. Request the patient sign the AMA form. a. If the patient refuses to sign the AMA form, the form should be completed, read to the patient (if possible) and witnessed by the facility personnel present. The statement 'refused to sign' or 'signature refused' should be written on the form..."

On 7/9/20 at 1:30 PM, Patient #3's electronic medical record was reviewed with Quality and Safety Manager D who confirmed the following:

Patient #3 arrived to the Emergency Department on 5/18/20 at 1:57 PM via ambulance with a chief complaint of 2 episodes of syncope (fainting) earlier in the day.

At 4:31 PM, "Patient Care Timeline" revealed, "ED Disposition set to Admit."

At 6:19 PM, while Patient #3 was still in the ED, "ED Quick Updates" revealed, "Pt (patient) upset, mad. PT requesting to leave. PT throwing things in room. PT made aware [he/she] can leave at [his/her] will and [he/she] will be leaving against medical advice. Pt dressing, hospitalist made aware."

Patient #3 left the department at 6:20 PM.

At 6:23 PM, "ED Notes" revealed, "...patient is requesting to leave AMA as [he/she] is upset and mad with staff regarding a variety of issues, including but not limited to delays with admission, refusal to speak with registration about observation admission, demands for meal tray and for staff to 'change [his/her] depends' even though patient is fully capable of perforning this care for [him/her]self. [Hospitalist] in department during this incident and is aware that patient is leaving. Per [Registered Nurse], patient was throwing things in ED room and arguing with ED RN because [his/her] requests were not being fulfilled to [his/her] liking. Pt can be heard on personal phone with ?family and arranging transportation home. Pt observed ambulating out of room and down hall towards ED waiting room - steady gait observed. IV was discontinued prior to pt leaving..."

There was no AMA form found in Patient #3's medical record. There was no evidence that Patient #3 was informed of the risks associated with leaving against medical advice per facility policy.

During an interview on 7/15/20 at 11:28 AM, when asked to confirm there was no AMA form in Patient #3's medical record, ED Supervisor C stated, "There is no AMA form on this one, correct. I remember I talked to the nurse about why we need one done after this."