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Based on record review and interview, the Hospital failed to ensure the patient's rights were protected and promoted as evidenced by the Hospital failed to ensure the patient/responsible party was given the information needed in order to make an informed decision regarding his/her care prior to leaving the hospital against medical advice (AMA) in accordance with the hospital's policy for 1 (#3) of 2 (#1, #3) sampled patients reviewed that left the hospital AMA out of a total sample of 5.

Findings:

Review of the Hospital policy titled Patient Rights revealed in part the following: The patient or his/her representative has the right to make informed decisions involving his/her care planning and treatment (as allowed by state law). The patient has the right to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate....

Review of the Hospital policy titled Patient Discharge, revealed in part the following:
Patient leaving AMA (Against Medical Advice):
If a patient has expressed a desire to leave against medical advice and all reasonable efforts have been made to prevent a patient form leaving the hospital, the following procedure will be implemented.
An AMA release form is to be completed by the nurse and signed by the patient. If the patient refuses to sign the AMA form, the nurse will document the refusal in the patient's record.
The patient's physician must be notified of the patient's decision.
The patient's family or responsible party will be notified that the patient is leaving AMA.
Document the physician and/or nurses' discussion of all potential risks of leaving.
Remove identifying armbands, IV lines, tubes, and other medical equipment prior to the patient leaving.
Never let an incompetent patient leave AMA. The physician, family and social services/case management must be notified immediately if this situation occurs.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 75 year old admitted to the hospital on 06/29/17 with diagnoses of Respiratory Failure, Pulmonary Emboli, Tracheostomy, Ventilator Dependent, Subdural Hematoma from fall with Right Hemicraniectomy and Cranioplasty, Deep Vein Thrombosis, and PEG tube. Review of the record revealed the patient was admitted to the hospital for PT/OT/ST, wound care, dietician, telemetry/cardiac monitor, and ventilator weaning.

Review of the record revealed a form titled, "An Important Message from Medicare about your Rights" that revealed the patient's daughter signed 08/10/17 at 8:00 a.m., and "Pt. AMA" was hand written in beside her signature in a different hand writing.

Review of the AMA (Against Medical Advice) Document revealed the following:
I certify that (I) Patient #3 a patient in Ochsner Extended Care Hospital of Kenner am leaving the hospital against the advice of the attending physician and the hospital administration. I acknowledge that I have been informed of the risk involved and hereby release the attending physician, and the hospital from all responsibility and any ill effects which may result from this action.
Patient/Representative Signature: Signed by Patient #3's spouse and dated 08/10/17
Witness Signature: Signed by Patient #3's daughter and dated 08/10/17.
Witness Signature: Signed by S4CM. There was no time documented on the form.

Review of the physician progress note dated 08/10/17 at 8:12 a.m., documented by S5Physician revealed no documentation that the risks of leaving AMA were explained to the patient or the patient's family. Further review of the physician progress notes from 08/05/17 to 08/09/17 revealed no documented evidence of any reference to the patient/patient representative leaving AMA.

Review of the Discharge Summary documented by S5Physician revealed the following: "Family decided to take patient back to Hospital A where he has all his specialist-cardiology, and pulmonology." There was no documented evidence that the physician explained the risks of leaving AMA to the patient or patient representative, and there was no documentation in the progress notes indicating the patient left AMA.

Review of the Nurses Daily Flow Sheet dated 08/10/17 revealed the following total documentation for the 7:00 a.m. to 7:00 p.m. shift:
7:00 a.m. - Report received from night nurse. Wife at bedside. No complaints.
9:00 a.m. - See nursing flow sheet for complete assessment. Will continue to monitor.
5:10 p.m. - Patient discharged via ambulance all IV fluids and tube feeding disconnected. The entries were signed by S6RN.
There was no documentation related to the patient leaving AMA, no documentation that the risks were explained to the patient/family, or how the patient who was on ventilator support at the time, was transported out of the hospital.
There was no documentation in the record that the physician was notified of the patient leaving AMA.

Review of the Resource Management Progress Notes (Case Manager Notes) revealed in part the following:
08/10/17 at 9:30 a.m. - Family decided to go AMA due to doctors/PCP/Cardiologist Care, all at Hospital A. Patient's wife can't clear (Transport) so they will be transported to Hospital A per Ambulance A. The entry was signed by S4CM. There was no documented evidence that the risks of leaving AMA were explained to the patient or patient representative. There was no documented evidence that the attending physician was notified of the patient leaving AMA.

In an interview on 10/03/17 at 9:06 a.m., S3RN, Charge Nurse on 08/10/17 indicated he did remember Patient #3. S3RN stated, "All I know is S4CM and S2DON said the patient is leaving AMA and had arranged transport." S3RN stated they do not assist with leaving AMA. S3RN stated he talked to the daughter and wife together and educated them about risks. He stated the family facilitated the transport. S3RN stated he told them it was a "bad idea." S3RN stated the family was fully informed and understood what AMA meant.

In an interview on 10/03/17 at 10:08 a.m., S4CM confirmed he was an LPN and the Case Manager and remembered Patient #3. S4CM stated the patient's wife and daughter called all his physicians at Hospital A and none of them would accept them. S4CM stated the patient's daughter said to him, "They (Hospital A) would have to take him if he showed up in ER." S4CM stated the patient's daughter would not let the hospital call Hospital A for transfer because she thought we wanted him to stay here for insurance. S4CM confirmed the signatures on the AMA form were the patient's wife, daughter, and his. He stated he did explain to them that the hospital may be on diversion and may not have a bed and have to send him somewhere else. S4CM stated S5Physician went over all the risks during a conference the day before. S4CM stated he explained how they would put the patient at risk by moving him. S4CM stated he explained AMA to the patient's wife repeatedly and he knew she understood. S4CM stated he explained that this was not a safe discharge, the patient could code, anything could go wrong, rides are rocky, anything can happen. Stated he asked, "Are you aware of the dangers and risks," and both the wife and daughter confirmed they were aware and understood. Both stated they thought they were making the right decision. When asked who made the arrangements for the patient's transportation, S4CM stated the patient's daughter called but we called behind them because the patient had to have a ventilator. After reviewing the nurse notes, physician progress notes, and his notes, he confirmed the record did not reflect the information he provided above. After review of the hospital policy for patient discharge, he confirmed the policy indicated the patient's physician would be notified of the patient's decision of AMA and the physician and the nurse would document the potential risks of leaving AMA in the record.

In an interview on 10/03/17 at 12:00 p.m., S5Physician confirmed she remembered the patient. S5Physician stated she informed the family the hospital could not transfer him for services this hospital provided. S5Physician stated when the family wanted to discharge the patient she informed them that she could not because he was not stable and she could not transfer the patient for services that could be provided here. S5Physician stated she did explain to family the risks of leaving AMA. S5Physician stated the patient's daughter stated they had a cardiologist that would accept the patient, but that never happened. S5Physician stated, "We figured it would be an easy transition if they went to the ER." S5Physician stated she did explain the risks of leaving AMA to the family. After reviewing the physician progress notes and discharge summary, and notes from her computer, S5Physician confirmed she had failed to document the risks of leaving AMA had been discussed with the patient/family.

In an interview on 10/03/17 at 3:32 p.m., S2DON confirmed that she remembered Patient #3 and his daughter and his wife. S2DON stated she spoke to the family about a lot of things. S2DON stated she knew they were disappointed in his progress or lack thereof. S2DON stated they were planning to discharge the patient to a lower level of care. When asked if she was aware the patient left the hospital AMA, she did not respond and stated she was trying to remember if she was here. After reviewing the medical record for Patient #3, she confirmed there was no documented evidence the risks of leaving AMA were explained to the family.

In a telephone interview on 10/04/17 at 12:17 p.m., the daughter of Patient #3 stated she told S1ADM that they wanted to leave the hospital and he told her he would pay for the ambulance. When asked if the risks of leaving the hospital AMA were explained to her and her mother, she stated they just said to, "sign here." When asked who made the arrangements for the transportation, she stated she guessed the case manager made the arrangements. When asked who initiated the AMA she said he needed to get to Hospital A and they (hospital) said, "You will have to sign AMA." She stated, "We didn't know." She stated she begged the hospital to transfer him but they kept saying he was almost ready for rehab. She stated she went to the case manager's office and when she told them she wanted to leave, the case manager and S1ADM said, "You will have to leave AMA." She stated they did not explain why. When asked if the staff explained the risks of leaving AMA, she stated all the staff did was show the bottom of the form and said, "This is where you sign." She stated she did not get an opportunity to even read the form. She stated, "They said him going on a vent assures they can't turn him away."

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failing to assess the patient's vital signs from 8:00 a.m. to 8:00 p.m. for a patient in Sinus Tachycardia with a sustained heart rate in the 130s for 1 of 1 (#3) sampled patients reviewed for vital signs out of a total sample of 5 (#1-#5).

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 75 year old admitted to the hospital on 06/29/17 with diagnoses of Respiratory Failure, Pulmonary Emboli, Tracheostomy, Ventilator Dependent, Subdural Hematoma from fall with Right Hemicraniectomy and Cranioplasty, Deep Vein Thrombosis, and PEG tube. Review of the record revealed the patient was admitted to the hospital for PT/OT/ST, wound care, dietician, telemetry/cardiac monitor, and ventilator weaning.

Review of the Graphic/I&O Sheet dated 08/05/17 and 08/06/17 revealed the patient's vital signs were documented every 4 hours. The heart rate was documented as 123-130 on 08/05/17 and 111-135 on 08/06/17. There was no documented evidence of the patient's blood pressure, heart rate, respiratory rate or temperature from 8:00 a.m. to 8:00 p.m. on 08/07/17. Further review of the Nurses Daily Flow Sheet and the MAR for 08/07/17 revealed no documented evidence of the patient's heart rate or blood pressure from 8:00 a.m. to 8:00 p.m.

In an interview on 10/05/17 at 11:00 a.m., S2DON reviewed the patient's medical record and confirmed there was no documented evidence of the patient's vital signs on 08/07/17 from 8:00 a.m. to 8:00 p.m. S2DON confirmed the vital signs should have been documented every 4 hours and she confirmed the patient was in Sinus Tachycardia with a heart rate in the 130s from 08/05/17 to 08/08/17.

Based on record review and interview, the hospital failed to ensure drugs were administered in accordance with physician orders as evidenced by failure to have documented evidence that patients received medications as ordered by the physician for 1 of 1 (#3) sampled patient records reviewed for medication administration from a total sample of 5 (#1-#5) patients.

Findings:

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 75 year old admitted to the hospital on 06/29/17 with diagnoses of Respiratory Failure, Pulmonary Emboli, Tracheostomy, Ventilator Dependent, Subdural Hematoma from fall with Right Hemicraniectomy and Cranioplasty, Deep Vein Thrombosis, and PEG tube. Review of the record revealed the patient was admitted to the hospital for PT/OT/ST, wound care, dietician, telemetry/cardiac monitor, and ventilator weaning.

Review of the physician orders dated/timed 08/07/17 at 9:50 a.m., revealed an order for Lopressor (Beta blocker for high blood pressure and elevated heart rate) 5 mg. IV push now. Review of the MAR dated 08/07/17 revealed the Lopressor was transcribed onto the MAR, but there was no documented evidence that the medication was administered to the patient.

Review of the MAR dated 08/09/17 revealed there was no documentation that the following medications were administered as ordered at 9:00 p.m. to Patient #3:
Sodium Chloride (Electrolyte) 1 gram per PEG tube twice daily at 9:00 a.m. and 9:00 p.m.
Juven (Nutritional supplement) 1 packet per PEG tube twice daily per at 9:00 a.m. and 9:00 p.m.
Elavil (Antidepressant) 10 mg. per PEG tube at bedtime.
Lactobacillus rhamnosus (Culturelle-probiotic) 4 capsules per PEG tube three times a day at 9:00 a.m., 3:00 p.m., and 9:00 p.m.
Guaifenesin (Expectorant) 100 mg per PEG tube three times daily at 9:00 a.m., 3:00 p.m., and 9:00 p.m.
Sotalol (Betapace-Beta blocker for blood pressure and elevated heart rate) 120 mg. per PEG tube twice daily at 9:00 a.m. and 9:00 p.m.
Midodrine (Low blood pressure support) 10 mg. per PEG tube three times daily at 9:00 a.m., 3:00 p.m., and 9:00 p.m.
Further review of the MAR dated 08/09/17 revealed there was no documented evidence the Zosyn (Antibiotic) 4.5 grams IV every 8 hours at 2:00 p.m., 10:00 p.m. and 6:00 a.m. was administered to the patient at 10:00 p.m. and 6:00 a.m.

Review of the MAR dated 08/10/17 revealed Cymbalta 20 mg. was to be administered per PEG tube twice daily at 9:00 a.m. and 9:00 p.m. The 9:00 a.m. dose was circled with, "Not available in Pixis" written in bedside the time. There was no documented evidence of any attempt to obtain the prescribed medication.


In an interview on 10/05/17 at 11:00 a.m., S2DON reviewed the MAR dated 08/07/17 and confirmed there was no documentation that the Lopressor was administered to Patient #3 as ordered on 08/07/17. After reviewing the MAR dated 08/09/17, S2DON confirmed the nurse had failed to document the Sodium Chloride, Juven, Guaifenesin, Sotalol, and Midodrine were administered as ordered at 9:00 p.m. S2DON confirmed the nurse was to draw a line through the time and initial below the scheduled time to document the medication was administered. S2DON confirmed there was no documented evidence that the Zosyn was administered at 10:00 p.m. and 6:00 a.m. on 10/09/17. After reviewing the MAR dated 08/10/17 and the nursing documentation, S2DON confirmed there was no documented evidence that the 9:00 a.m. dose of Cymbalta was administered to the patient and there was no documented evidence of any attempts to obtain the medication. At 12:00 p.m., S2DON provided an override document indicating the Lopressor was removed from the medication dispensing system on 08/07/17 but confirmed there was no documented evidence it was administered.

Based on record review and interview, the Hospital failed to ensure the patient/patient representative requesting transfer to another facility was assisted in making arrangements for transfer to the facility of choice and the necessary medical information was provided to the receiving hospital for 1 (#3) of 4 (#2, #3, #4, #5) sampled patient's reviewed for transfers. This deficient practice was evidenced by the patient's representative having the patient who was ventilator dependent, leave the Hospital against medical advice (AMA) by ambulance and transported to the emergency department of another hospital.

Findings:

Review of the Hospital policy titled Patient Transfer, revealed in part the following: To establish guidelines to ensure that adequate care is given to each patient when: Transferring a patient to another facility that offers an appropriate level of care....Once the decision to transfer has been made, it will be the responsibility of the social worker, case manager, or designated hospital representative to make arrangements for the transfer. They will assure there is an accepting physician for that facility.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 75 year old admitted to the hospital on 06/29/17 with diagnoses of Respiratory Failure, Pulmonary Emboli, Tracheostomy, Ventilator Dependent, Subdural Hematoma from fall with Right Hemicraniectomy and Cranioplasty, Deep Vein Thrombosis, and PEG tube. Review of the record revealed the patient was admitted to the hospital for PT/OT/ST, wound care, dietician, telemetry/cardiac monitor, and ventilator weaning.

Review of the AMA (Against Medical Advice) Document revealed the following:
I certify that (I) Patient #3 a patient in Ochsner Extended Care Hospital of Kenner, am leaving the hospital against the advice of the attending physician and the hospital administration. I acknowledge that I have been informed of the risk involved and hereby release the attending physician, and the hospital from all responsibility and any ill effects which may result from this action.
Patient/Representative Signature: Signed by Patient #3's spouse and dated 08/10/17
Witness Signature: Signed by Patient #3's daughter and dated 08/10/17.
Witness Signature: Signed by S4CM. There was no time documented on the form.

Review of the Discharge Summary documented by S5Physician revealed the following: "Family decided to take patient back to Hospital A where he has all his specialist-cardiology, and pulmonology." There was no documented evidence that the physician explained the risks of leaving AMA to the patient or patient representative, and there was no documentation in the progress notes indicating the patient left AMA. There was no documented evidence of any attempts to transfer the patient.

Review of the Resource Management Progress Notes (Case Manager Notes) revealed in part the following:
08/10/17 at 9:30 a.m. - Family decided to go AMA due to doctors/PCP/Cardiologist Care, all at Hospital A. Patient's wife can't clear (Transport) so they will be transported to Hospital A per Ambulance A. The entry was signed by S4CM. There was no documented evidence that the risks of leaving AMA were explained to the patient or patient representative. There was no documented evidence of any attempts to transfer the patient on 08/10/17.

In an interview on 10/03/17 at 9:06 a.m., S3RN, Charge Nurse on 08/10/17 indicated he did remember Patient #3. S3RN stated, "All I know is S4CM and S2DON said the patient is leaving AMA and had arranged transport." S3RN stated they do not assist with leaving AMA. S3RN stated he talked to the daughter and wife together and educated them about risks. He stated the family facilitated the transport. S3RN stated he told them it was a "bad idea." S3RN stated the family was fully informed and understood what AMA meant. S3RN stated if the family wanted to transfer the patient they would have voiced that to the case manager or leadership. S3RN stated the family was given options for discharge, but the options were not acceptable to family. He stated custodial care on a ventilator was not what they wanted. S3RN stated the family had been talking about going someplace else before the day they left. S3RN stated, "This was not a surprise, everybody knew what was going to happen."

In an interview on 10/03/17 at 10:08 a.m., S4CM confirmed he was an LPN and the Case Manager and remembered Patient #3. S4CM stated the patient's wife and daughter called all his physicians at Hospital A and none of them would accept them. S4CM stated the patient's daughter said to him, "They (Hospital A) would have to take him if he showed up in ER." S4CM stated the patient's daughter would not let the hospital call Hospital A for transfer because she thought we wanted him to stay here for insurance. S4CM stated the family wanted the patient on the west bank where they live and the daughter stated she was tired of driving over here. They just wanted to be at Hospital A where his doctors were so her mom could get a ride to that facility since they lived down the street. He stated he offered repeatedly to make arrangements for a transfer to Hospital A. After reviewing the nurse notes, physician progress notes, and his notes, he confirmed the record did not reflect the information he provided above.

In an interview on 10/03/17 at 12:00 p.m., S5Physician confirmed she remembered the patient. S5Physician stated she informed the family the hospital could not transfer him for services this hospital provided. S5Physician stated when the family wanted to discharge the patient she informed them that she could not because he was not stable and she could not transfer the patient for services that could be provided here. S5Physician stated the patient's daughter stated they had a cardiologist that would accept the patient, but that never happened. S5Physician stated, "We figured it would be an easy transition if they went to ER." S5Physician stated she did send information with the patient, a medication list. She stated she told the staff to send it. S5Physician stated, "Usually with AMA we don't give information but I knew they needed that information." S5Physician stated S4CM did not tell her that the family did not want the hospital to arrange a transfer. She stated S4CM usually arranges transfers with the accepting physician. S5Physician stated the family would have to give S4CM the contact information. S5Physician stated she would have called if she had the contact information. S5Physician stated the family had been talking about a transfer for days. After rounds on 08/10/17, she was notified by staff that the family wanted to leave. S5Physician stated the patient's daughter was very upset and wanted her father to see his cardiologist.

In a telephone interview on 10/04/17 at 12:17 p.m., the daughter of Patient #3 stated she told S1ADM that they wanted to leave the hospital and he told her he would pay for the ambulance. When asked if the risks of leaving the hospital AMA were explained to her and her mother, she stated they just said, to "sign here." When asked who made the arrangements for the transportation, she stated she guessed the case manager made the arrangements. When asked who initiated the AMA she said he needed to get to Hospital A and they (hospital) said, "You will have to sign AMA." She stated, "We didn't know." She stated she begged the hospital to transfer him but they kept saying he was almost ready for rehab. She stated she went to the case manager's office and when she told them she wanted to leave, case manager and S1ADM said, "You will have to leave AMA." She stated they did not explain why. When asked if the staff explained the risks of leaving AMA, she stated all the staff did was show the bottom of the form and said, "This is where you sign." She stated she did not get an opportunity to even read the form. She stated, "They said him going on a vent assures they can't turn him away."