HospitalInspections.org

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Based on document reviews and interviews, Facility A failed to ensure patient medical records were properly filed and retained, and accessible or ensure that medical record entries are not lost, stolen, destroyed, altered for 1 of 20 patient medical records (Patient #2). Facility A failed produce for review a signed copy of Patient #2's AMA (against medical advice) document for review.
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Findings:
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Medical Record Review:
On 2/18/2025 at 8:19 PM, Patient #2 was admitted to Facility A's Emergency Department (ED) via ambulance with Little Elm Police Department on an APOWW (apprehension by police without a warrant) for suicide attempt. Patient #2 was screened while in the ED and found to be in DKA (diabetic ketoacidosis). Patient #2 was admitted to Facility A's ICU for management of her blood glucose levels on 02/19/2025 at 12:37 AM. Following a call from Patient #2's Dad, Frisco Police Department (FPD) was dispatched to Facility A on 02/19/2025 at approximately 11:37 AM because Patient #2 had signed out AMA (against medical advice) and was attempting to leave.
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A review of Patient #2's medical record revealed Patient #2 had signed herself out AMA from Facility A on 02/19/2025 when it was documented on 02/19/2025 at 10:30 AM in Nursing Notes by ICU RN (Staff #27):
"RN asked if pt (Patient #2) understood the risks of leaving AMA (against medical advice). Pt (Patient #2) stated she understands. RN let pt (Patient #2) know that security will be up to escort her out. Pt (Patient #2) calmly agreed and said she will wait for security. MD, Charge nurse, and security notified. RN also contacted non-emergent FPD (Frisco Police Department) line to notify of pt (Patient #2) leaving hospital facility. Per (a named person) at FPD officers had already been dispatched to hospital and already on site per request of pt's (Patient #2's) father (Jim) who had called them himself. Upon arrival of security and FPD officers to pt (Patient #2). Pt (Patient #2) standing in doorway. FPD asked if pts name is (stated name of Patient #2) and pt (Patient #2) nodded her head "no" and immediately started running through the unit doors attempting to get away but was then tackled to the ground and restrained on the ground by 3 officers. On the leadership, (Staff #5), (Staff #17), (Staff #3), Charge nurse, and (Staff #1/6) present in hallway during this time.
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Policy Reviews:
Facility A's Against Medical Advice (AMA) Policy, last reviewed and implemented on 09/2021, stated on page 1 of 1:
" ...The Leaving Against Medical Advice Form provides documentation that:
1. A competent patient insists upon leaving, or that the competent parent/legal guardian of a minor insists upon taking the minor out of the hospital after being informed by the physician of the patient's medical condition and risks of leaving against medical advice.
2. The competent patient was advised not to leave the hospital.
3. The competent patient's discharge is solely his/her own responsibility.
4. The competent patient is acting of his/her own free will and volition.
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The Leaving Against Medical Advice form will be completed when:
1. A competent adult patient insists upon leaving the hospital when he/she is still in need of medical care.
2. The competent parent/legal guardian of a minor insists upon taking the minor from the hospital when he/she is still in need of medical care ..."
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FPD body camera reviews revealed the following:
A review of FPD's body camera footage from 4 different Police Officers revealed that video surveillance supported that Patient #2 had signed the AMA, Facility A's physician and staff were aware of Patient #2 signing an AMA and were initially comfortable in allowing Patient #2 to leave Facility A because of the signed AMA.
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Per body camera reviews from FPD Officer Miller, at time marker 09:24 - Staff #5 (the ICU Hospitalist caring for Patient #2) stated, "I'll be honest with you. It was my understanding ...I could be wrong here ...my understanding was that irrespective of an APOWW, we have, as a hospital, a medical care team, are unable to physically or chemically restrain someone ..."
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Per body camera reviews from FPD Officer Miller, at time marker 09:46 - Staff #5 continued, "I could be wrong here, but I am to rely on the hospital leadership to know ..."

Per body camera reviews from FPD Officer Miller, at time marker 10:43 - Staff #5 then stated, "So this hospital ..we do not ... we have telepsychiatry and the patient (Patient #2) had to agree to do the tele psych evaluation and she (Patient #2) refused that, so I think that may be the issue."
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Per body camera reviews from FPD Officer Miller, at time marker 11:50 - .....Staff #5 began to say that the hospital allowed them (patients) to leave and once they left, they called the police.
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Per body camera reviews from FPD Officer Miller, at time marker 13:43 - Staff #5 stated that by his perspective, Patient #2 had gone AMA.
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Per body camera reviews from FPD Officer Wilkinson, at time marker 4:51 - Staff #3 (the House Supervisor) bent down and told the officers that she (Patient #2) does not have a room, that she (Patient #2) had signed out AMA (against medical advice).
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Per body camera reviews from FPD Officer Wilkinson, at time marker 5:09 - Staff #3 stated that (Patient #2) signed out AMA.
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INTERVIEWS:
Staff #B (the Director of Quality) was interviewed on 04/08/2025 between 9:00 AM and 3:00 PM. Staff #B was informed that Patient #2's AMA document could not be located within the medical record provided and asked to see if she could find it for review. Staff #B looked through the electronic record and checked with HIM (Health Information Management) to see if the document was still pending being scanned into the electronic record. HIM did not have the document. Staff #B asked her Assistant (Staff #D, RN) to look and she could not find the document.
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Staff #B was asked where the AMA form was usually placed. Staff #B indicated that since it was a part of the medical record it should have gone to HIM to be scanned into the electronic record.
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Staff #B then asked the Emergency Department (ED) Director (Staff #24) to see if he could find the document. When Staff #24 could not locate the document, he was interviewed on 04/08/2025 at 2:30 PM. Staff #24 was asked where the AMA form was usually placed. Staff #24 indicated that since it was a part of the medical record it should have gone to HIM to be scanned into the electronic record.
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An interview was conducted with Staff #A (the Vice President of Quality) was interviewed on 04/07/2025 between 1:30 PM and 4:00 PM. During the interviews, Staff #A indicated that is was not Facility A's practice or policy to allow a patient admitted under an APOWW (apprehension by police without a warrant) to sign out AMA (against medical advice) until cleared by psychiatry/behavioral health.
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Staff #A was interviewed again on 04/08/2025 at around 9:30 AM. Staff #A was asked to produce a copy of the signed AMA form for Patient #2 and informed that other Facility A staff had looked for but could not find the document and had checked with HIM. Staff #A indicated that she did not know where the form was but that it had been revoked anyway. Staff #A indicated that the form was not intentionally removed or destroyed but that she did not know where it was.
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Staff #A was asked where the AMA form was usually placed. Staff #A indicated that since it was a part of the medical record it should have gone to HIM to be scanned into the electronic record.
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