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SSM HEALTH ST ANTHONY HOSPITAL - OKLAHOMA CITY 1000 NORTH LEE AVENUE OKLAHOMA CITY, OK 73101 July 19, 2017
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the facility failed to provide evidence of the AMA form for 3 of 3 AMA charts (# 2, # 4 and # 5) .

A hospital policy titled "Against Medical Advice (AMA)" documented the ED physician will disposition the patient as an AMA and print the AMA form having the nurse obtain the patient's signature. If the patient refuses to sign or leaves prior to signing the form, the form is completed and signed by two witnesses. Both must be employees of SAH (one must be an RN) with a written statement of reason why the form was not signed by the patient.

3 of 3 AMA charts (# 2, # 4 and # 5) reviewed did not contain the AMA form.

On 07/18/17 at 1:30 pm, Staff B stated the staff attempts to have two witnesses sign AMA form per policy.

On 07/19/17 at 9:25 am, Staff A stated the staff did not follow the policy.