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Based on clinical record review and interview, it was determined the Facility failed to fully disclose the risks and benefits of transfer specific to the condition of the transferred patients. Failure to fully disclose the risks and benefits did not allow four (Patients #3, #8, #16, and #19) of four (Patients #3, #8, #16 and #19) patients to make an informed decision regarding the need for the transfer. The failed practice was likely to affect Patients #3, #8, #16 and #19. Findings follow:

A. Review of the clinical records of Patients #3, #8, #16 and #19 revealed no documentation of the risks and benefits specific to the condition for which the patient was being transferred for.

B. During clinical record review with the Director of Quality at 1345, 1435, 1540 and 1005 respectively, on 06/30/15 and 07/01/15, verified the findings.