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Based on interview and record review the facility failed to ensure that the signed and dated consent form explaining the risks and benefits statement was not explained or completed by the patient or their representative for 1 of 10 patients (patient #10) that was transferred to another hospital.

Findings:

Review the chart showed Patient # 10 was transferred from the emergency department to another hospital for a higher level of care on 02/14/2015. The discharge assessment showed the patient was awake and alert. No apparent distress. The Emergency Department Transfer Certification Form showed the signature of the physician on 02/14/2015 at 5:36 PM and the signature of the Registered Nurse, not the patient. There were no notes in the chart to indicate why the nurse signed for the patient. Additional chart documentation showed the family was at the bedside of the patient. The transfer log and the Transfer Certification Form showed the patient was transferred to Hospital A. The nurses notes showed the patient was transferred to Hospital B.

An interview on 04/06/2015 at 2:30 PM with the Chief Nursing Officer revealed an investigation will be done to determine why the nurse signed the document and Patient #10's transfer form is being located.

Review of the Administrative Policy and Procedure Titled: Emergency Patients-Acceptance and Transfer Revised: February 2015 revealed:

Requirements For An Appropriate Transfer
An appropriate transfer to nearest medical facility with service capacity is a transfer in which
1. A physician has signed a certification that, based upon the information available at the time of transfer, the medial benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the patient and, in the case of labor, to the unborn child, and
2. The transferring hospital provides medical treatment within its service capability and service capacity, which minimizes the risks to the patient's health, and, in the case of a woman in labor, the health of the unborn child
4. The transferring hospital sends to the receiving facility all medical records and the informed written consent or physician's certification that benefits of transfer outweigh the risks, and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment