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Based on record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for four of eight medical records of transferred patients reviewed (Patient #5, #7, #8, and #9). A total of 20 medical records were reviewed. The hospital registered 57,087 patients in the emergency department in the preceding six months prior to the survey.

Findings include:

1. Review of the medical record for Patient #5 revealed an arrival date of 07/24/21 at 10:00 AM to the emergency department. The medical record contained documentation the patient had uncomplicated alcohol dependence and wished to go to a detox center. The medical record contained documentation the patient was transferred to another facility with an alcohol rehabilitation program on 07/25/21 at 12:46 AM. The medical record lacked documentation of a physician signed transfer form including a summary of the risks and benefits of the transfer.

2. Review of the medical record for Patient #7 revealed an arrival date of 06/28/21 at 12:44 PM to the emergency department. The medical record contained documentation the patient was having hallucinations and psychosis. The medical record contained documentation the patient was transferred to a psychiatric facility on 06/29/21 at 9:03 AM. The medical record lacked documentation of a physician signed transfer form including a summary of the risks and benefits of the transfer.

3. Review of the medical record for Patient #8 revealed an arrival date of 07/03/21 at 9:46 PM to the emergency department. The medical record contained documentation the patient had diagnoses of bipolar and alcohol use disorder. The patient had an "Application for Emergency Admission" form stating the patient represented a substantial risk to self and would benefit from treatment in a hospital for mental illness. The medical record contained documentation the patient was transferred to a psychiatric facility on 07/04/21 at 1:34 PM. The medical record lacked documentation of a physician signed transfer form including a summary of the risks and benefits of the transfer.

4. Review of the medical record for Patient #9 revealed an arrival date of 08/31/21 at 6:01 PM to the emergency department. The medical record contained documentation the patient had diagnoses of depression with suicidal ideation. The patient had an "Application for Emergency Admission" form stating the patient represented a substantial risk to self and would benefit from treatment in a hospital for mental illness. The medical record contained documentation the patient was transferred to a psychiatric facility on 09/01/21 at 12:57 AM. The medical record lacked documentation of a physician signed transfer form including a summary of the risks and benefits of the transfer.

In an interview on 11/04/21 at 11:10 AM, Staff A verified a physician signed transfer form should have been completed for Patient #5, #7, #8, and #9, but transfer forms could not be located for these patients.