when patients go off the floor...

ScarryBear,RN · Mar 28, 2012

Just a point of clarification. You can't legally force a patient to sign an AMA form....or anything else for that matter. Sure you can try to talk them into it, but if they refuse there's really nothing you can do but document it. And except in very limited and specific circumstances, you can not legally prevent them from getting up and going for a walk if they choose to do so. About the only way to handle this is to have policies in place as some have described, and even then you have to be careful not to over do it. Policies that are overly restrictive or punitive could get you on the wrong side of CMS, among others.
Patients are not prisoners. They have the absolute right to make any and all decisions redarding their treatment if they so choose, including the right to refuse any specific test, treatment or procedure without prejudice to any other needed care. This would include not being allowed to get out of bed or go for a walk if they are able to do so. You can and should attempt to educate them, but if they choose not to listen, there's not a whole lot you can do.

I understand your point and I totally agree with you. I have fought against our hospitals' policy since I started because there are young patients who may want to take a visiting child for a walk for example who are relegated to our floor or their room because they are on and antidepressant.(any type of phych meds even prozac automatically jumps the fall risk score up ten points)

If a patient leaves the floor or goes outside they are automatically listed as an elopement. If we find them and they choose to come back they have a choice of signing out AMA or staying and agreeing to not leave the floor again. If they choose to leave they can sign the AMA paper, however if they leave without telling anyone or refuse to sign the paper we have to call the local police. I know it's absurd. I feel like we have degraded back to a time when hospitals were convalescence homes where everyone had to stay in bed behind waited on hand and foot.

NicuGal, MSN, RN · Mar 28, 2012

I think that much of this is stemming from the fact that many of the hospitals are going non-smoking and you cannot smoke on property, therefore the patients are leaving hospital property while still under our care. This creates a problem. Ours stemmed from a guy who left,went up two streets to be off property to smoke, collapsed and was found by our security on patrol. They were able to get him in the cruiser and bring him back, but legally, we were responsible for that patient as he is under our care. We had patients with chest tubes, IV poles, etc out and about...sorry but that is a HUGE liability.

The whole policy is outlined when they are admitted, not only to them, but to the family. If they refuse to sign the AMA, then we discharge them against medical advice and document it.

I'm all for patients being able to get up and go to the cafe or lunch area or the library, or out to the green space, but we have to be able to keep track of them somehow as they are our responsibility and we are to supposed to be keeping them safe while with us. In the age of litigation, you have to cover your behind!

betterlatethennever · Mar 28, 2012

IF a person is sick enough to be hospitalized then they should not be allowed to leave the floor. The first hospital I worked at patients were not allowed to leave the floor period. Then I worked at a hospital in a large metropolitan city and patients were all over the hospital in the cafeteria, outside smoking, in the elevators it was crazy. I feel that they are under my care and my license. If they are on tele and go outside and have an MI that's going to be my behind. Yes patients have rights but we as nurses have a right to keep them safe. I just tell my patients that if they leave then they will be discharged from the hospital. If they are smokers I offer to get them a nicotine patch to keep them comfortable. If they want fresh air then an employee needs to escort them.

jbluehorseh · Mar 28, 2012

there are many valid points being made here in this forum.the issues of the patient bill of rights, aside; the bearer of responsibilityfalls up on the hospital and the nurse. onealso has to take into consideration the type and level of care of the patientis receiving. if a patient is a 27 male with no medical history in for an appythen it is no big deal for this patient to go outside. however if the patientis chronically sick and on a tele or pcu unit, then i say no the patient cannotgo down stairs. the patient is on that unit for a reason, they are being monitored24 hours a day for a reason. i do notcare if he or she has a right to because in the end it is our licenses that is atrisk and i doubt that the hospital would protect the nurse if the patient diedwhen patient went outside for fresh air, let alone went off campus.

letting thepatient go outside sounds great in theory, but there is an immense issue of liabilitythat comes with this issue. the hospital needs to have clear written policy forwho can and cannot go outside. this protects the nurse and hospital from beingsued. if the patient is well enough tooutside on his or her own power then the patient is probably ready to go homein most cases.

turnforthenurse, MSN, NP · Mar 29, 2012

just a point of clarification. you can't legally force a patient to sign an ama form...or anything for that matter

that is true. i've had patients leave ama and refuse to sign the form. a copy of the form goes into their chart and we document that the risks were explained, patient refused to sign ama form, charge rn, supervisor and attending physician notified, etc. if a patient leaves ama with their iv in place, we have to call the police.

we also offer nicotine patches along with smoking cessation counseling. some patients will request them; however, most do not. all we can do is document. some patients will attempt to smoke in their rooms...and it has happened on our unit before! the only time that is ever acceptable is if the patient is terminally ill and there is a written order from the physician (this is actually in our policies & procedures manual). there is to be no smoking on the hospital grounds but again, we were told we cannot hold the patient hostage in their room if they are stable enough to go walk downstairs.

there is still a liability issue, though. if something does happen downstairs, they are still technically under our care and then it falls on the primary rn taking care of that patient. even though we are told to document "risks explained of not being on the monitor downstairs, patient verbalized understanding" i'm not sure how that hold up in court if it came down to that. it seems like the ama form would be a means to get out of a liability issue but again, we can't force a patient to sign it! :uhoh3:

there are many valid points being made here in this forum.the issues of the patient bill of rights, aside; the bearer of responsibilityfalls up on the hospital and the nurse. onealso has to take into consideration the type and level of care of the patientis receiving. if a patient is a 27 male with no medical history in for an appythen it is no big deal for this patient to go outside. however if the patientis chronically sick and on a tele or pcu unit, then i say no the patient cannotgo down stairs. the patient is on that unit for a reason, they are being monitored24 hours a day for a reason. i do notcare if he or she has a right to because in the end it is our licenses that is atrisk and i doubt that the hospital would protect the nurse if the patient diedwhen patient went outside for fresh air, let alone went off campus.
letting thepatient go outside sounds great in theory, but there is an immense issue of liabilitythat comes with this issue. the hospital needs to have clear written policy forwho can and cannot go outside. this protects the nurse and hospital from beingsued. if the patient is well enough tooutside on his or her own power then the patient is probably ready to go homein most cases.

well said. :up:

CompleteUnknown · Mar 29, 2012

Wow, some of these policies seem incredibly restrictive. It's common where I am for patients to leave the floor to go for a walk or to the cafeteria or just to get some sun or fresh air. We do expect patients to discuss their plans with the nurse first, if they just disappear into thin air and no-one knows where they are, obviously that's an issue. All the same, I don't see how you can make a blanket rule that patients are not allowed to leave the floor, as another poster mentioned, they're not prisoners.

Some posters have mentioned that most patients are too sick to be walking anywhere and that's true, but there are also many patients who CAN walk and are quite capable of looking after themselves for half an hour or so. If they need a wheelchair and have a family member willing to push them, and are medically stable enough to do so, I'm all for patients getting a change of scene - it usually does them the world of good.

It all depends on the reason they're hospitalised, their general condition, and a multitude of other medical, behavioural and emotional factors. Anything can happen to anyone at any time but I don't think the possibility that I might fall in the grounds or the corridor should mean I'm not allowed to leave my room!

On a semi related note, there seems to be more and more black and white thinking in the healthcare area in recent times. Suggestions become guidelines and guidelines become rigid rules in the blink of an eye. What was okay for 99.9% of people yesterday becomes a dangerous practice today. I have to wonder where it will all end.

Roy Fokker, BSN, RN · Mar 29, 2012

Uhhh, nobody with an IV/hep-lock is allowed outside.

Anyone who is intoxicated (be it drugs or alcohol) isn't allowed outside - period.

This is especially true of our psych patients.

I'm not chasing someone down if they decide to bolt on me...

Sometimes I admit - as an ex-smoker I feel their anguish ("All I want is one *******' cigarette!") - but nope. Nope. Annnnd NOPE!

Maybe it's different because I work ER?

cheers,

sharkdiver · Mar 30, 2012

Our patients sign a no-smoking acknowledgement on admit. It states that should the patient be found outside smoking they shall be discharged against medical advice and insurance will likely not cover their stay. I've only seen one person do so anyway, but the nurse did not enforce it.

This is a good example of how good intentions can cross into unethical behavior. The premise that if a patient leaves AMA their insurance will not cover their stay is a complete myth - an urban legend of the medical variety. It simply isn't true - do the research. By lying to the patient in order to control their behavior the facility is engaging in an unethical practice. It also potentially brings their credibility into question - if they'll lie about something that mundane, what would they do about something really serious?

Your risk management folks need to look at this. It's fine to say that if they don't comply they may be discharged, but the language about insurance not covering their stay is, IMHO, inappropriate.

When a patient refuses to comply with a policy, the hospital is essentially limited to three options:

1. Attempt to accommodate the patient

2. Discharge the patient if their medical condition permits

3. Transfer them to another facility if it doesn't

NurseMikki · Mar 30, 2012

When I worked on the floor, I always worked on tele units. If you were sick enough to have your heart continuously monitored you'd have to sign AMA to go off the unit since not all areas of the hospital picked up the telelmetry signals. Plus if you were to have an arrythmia, would you really want to be running all over the hospital tyring to hunt down your pt?

nurseprnRN, BSN, RN · Mar 30, 2012

i worked a surgical floor once where we had a lot of junkies in for long-term q12h iv antibiotics for their endocarditis exacerbations. we got quite used to them leaving the floor -- with that nice central line in place-- right after breakfast and their 0800 dose, to return about 1730 for their evening dose and a gooooooood looooooong sleep.

JeneraterRN · Mar 31, 2012

Show me the info that states this is not true. All the info I have states this can happen. I don't recommend saying I'm lying to a patient without literature to back it up.

JeneraterRN · Mar 31, 2012

Ok, so I did some research outside of what the hospital gave me, and it seems true that insurance covers most AMA discharges. I learned something new, but I still bristle at stating I was lying to patients as this was what the hospital was teaching us. It seems administration was either seriously misinformed or lying, but I don't think staff was being malicious.