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A. Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for leaving the hospital against medical advice (AMA), the hospital failed to ensure that the physician notification was documented in nurse's note regarding Pt #1 leaving AMA, as required.

Findings include:

1. On 8/01/2023, the hospital's policy titled, 'Patients Who Leave Against Medical Advice' was reviewed and included, " ...3. The attending physician and unit leadership/designee should be notified immediately, and this action should be documented in the nurses' notes."

2. On 08/01/2023, the clinical record of Pt. #1 was reviewed. On 4/26/2023, Pt. #1 presented to the ED (Emergency Department) and was admitted as inpatient with a diagnosis of diplopia (double vision) and anisocoria (different sized pupils). The clinical record included:

-The form "Leaving Against Medical Advice (AMA)" dated 4/26/2023 at 8:13 PM included, " ...I am leaving (Hospital) at my insistence and against the advice of the hospital personnel, my attending physician or any other health care providers at the hospital in charge of my care...I have been informed by them of the dangers of my leaving at this time and the potential risks including the worsening of my condition, further injury, and possible death...I have been given the opportunity to ask any questions I wish concerning the above, and all such questions have been answered to my satisfaction...have read and understand its meaning." The AMA formed was signed by Pt. #1 at 8:13 PM.

-The ED Nursing Progress Note dated 4/26/2023 at 8:24 PM, included, "(Pt. #1) and family friend doctor are demanding the patient to be transferred to outside hospital (OSH) for further care ...Charge RN (registered nurse)explained the transfer process to the family doctor who did not approve of this process and became verbally aggressive and threatening ...House supervisor was made aware ... (Pt. #1) signed out AMA.." The clinical record lacked nursing documentation that the attending physician was notified.

3. On 8/3/2023 at approximately 9:30 AM, an interview was conducted with the ED Assistant Manager (E #4) and the Quality and Regulatory Staff (E #8). E #4 stated that both the attending physician and unit leadership should be notified of patients that leave the hospital AMA. E #4 stated the notification should be documented in the nurses' notes. E #8 stated that thorough review of Pt. #1's chart was performed and documentation regarding physician notification of Pt. #1 leaving AMA was not available for review.



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B. Based on document review and interview, it was determined that for 2 of 5 (Pt. #4 and Pt. #6) clinical records reviewed for patient reassessments in the ED (emergency department), the hospital failed to ensure that pain reassessments were conducted, as required.

Findings include:

1. On 8/1/2023, the hospital's policy titled, "Assessment and Reassessments in the Emergency Department" (8/2022) was reviewed and included, "... Process on the assessment and reassessment of patients within the Emergency Department (ED)... Procedure... Reassessment: To be carried out by an ED RN (registered nurse) or EMT-P (emergency medical technician - paramedic)... reassessment is due per the guidelines... This should include a... pain assessment... Level/ESI/emergency severity index 2: (at least every) 2 hours; Level 3: (at least every) 3 hours..."

2. On 8/1/2023, the clinical record for Pt. #4 was reviewed. On 7/30/2023, Pt. #4 came to the ED for opiod detoxification. Pt. #4 had an ESI of 2. There was no pain reassessments from 7/31/2023 at 7:22 AM through 8/1/2023 at 7:11 AM (23 hours and 49 minutes).

3. On 8/1/2023, the clinical record for Pt. #6 was reviewed. Pt. #6 came to the ED due to fever, nausea, and vomiting. Pt. #6 had an ESI of 3. On 8/1/2023, there was no pain reassessments from 1:29 PM through 7:59 PM (6 hours and 30 minutes).

4. On 8/2/2023 at approximately 12:00 PM, findings were discussed with E #4 (ED Assistant Manager). E #4 stated that pain reassessments were missing for Pt. #4 and Pt. #6. E #4 stated that pain reassessments should be conducted based on the ESI level (every 2-3 hours).