Observations
Based on a review of clients records and administrative documents, the facility failed to develop policies and procedures for notifying the emergency contact within twelve hours of leaving against medical advice in two of two applicable records.
Act 41 of 2021, 71 P.S. 613.1(8.1) states inpatient drug and alcohol treatment facilities must attempt to notify the emergency contact at least once and develop policies and procedures to implement a notification protocol.
Client #3 was admitted September 11, 2023 and discharged September 13, 2023 against medical advice. There was no documentation of the facility attempting to contact the emergency contact on file within 12 hours of discharge.
Client #5 was admitted October 28, 2023 and discharged October 30, 2023 against medical advice. There was no documentation of the facility attempting to contact the emergency contact on file within 12 hours of discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Update Hospital Policy 15 - Discharge of Patients Against Medical Advice (AMA) to include verbiage on contacting the emergency contact for Detox patients leaving AMA - COO, 2/14/24
Train Detox Unit Staff on Updated Hospital Policy 15 - Detox Unit Nurse Leader, 2/23/24
Update Detox Nursing Discharge assessment to include documentation of notification for emergency contact - IT informatics nurse, 2/23/24
Train Detox Nursing staff on updated DC assessment - Detox Unit Nurse Leader, 3/4/24
Audit all Detox AMA discharges for 1 month to ensure that the appropriate documentation is completed for patients who leave AMA - Detox Unit Nurse Leader, 4/1/24 |