HospitalInspections.org

Based on record review and interview, the facility failed to inform patients, in writing, of their potential risks for discharge against medical advice in 2 of 8 patients who left AMA (against medical advice) (Patient # 2 and Patient #13) in a total of 16 medical records reviewed.

Findings include:

Review of the facility policy titled, "Discharge Against Medical Advice" #11310906 dated 3/3/2022 revealed, "Policy: All persons... have the right to request discharge." Under Purpose C. revealed "to ensure proper notification and proper documentation in the patient's record." If the patient informs staff of the desire to leave,, they shall "assist the individual in creating the written request and present it to the individual to sign, date and time... The refusal ... to sign the request for discharge will be documented on the unsigned written request."

Patient #2's medical record revealed Patient #2 was dropped off at the facility by his caseworker 3/30/2023 at 5:00 PM and admitted voluntarily to the facility. Psychiatric evaluation dated 3/31/2023 at 1l:45 AM revealed Patient #2 "asked to be discharged the morning following admission." Patient #2 was discharged to a homeless shelter 3/31/2023 at 1:03 PM. There was no AMA form in Patient #2's medical record.

Pt. #13 was admitted to the facility on 4/20/2023 on an involuntary basis with a diagnosis of Delusional Disorder. Review of the medical record revealed that the court case to address the involuntary status was dropped and on 4/25/2022 Pt. #13 requested to leave AMA (Against Medical Advice). The Discharge Summary revealed, "There is no evidence that he/she was a danger to herself or others ...He/she was discharged Against Medical Advice." Review of the medical record did not reveal any AMA form.

In an interview on 5/04/2023 at 9:30 AM Director of Medical Records M stated, "We cannot find that form in (Patient. #2 or Patient #13's) medical records.