HospitalInspections.org

Based on clinical record review and interview, it was determined the Facility failed to disclose the risks and benefits of transfer specific to the condition for 2 (#2 and #3) of 5 transferred patients. Failure to disclose the risks and benefits specific to the condition did not allow Patient #2 and #3 to make an informed decision regarding the need for the transfer. The failed practice affected Patients #2 and #3

A. Review of the clinical records of Patients #2 and #3 revealed documentation of the risk and benefits were not pertinent to the condition for transfer.
1. Review of the clinical record for Patient #2 revealed a Transfer Certification Statement for 04/01/15 with a suspected diagnosis of "urosepsis". The risks of transfer were listed as "MVC (motor vehicle collision), worsening of condition". The benefits of transfer were listed as "More specialized care".
2. Review of the clinical record for Patient #3 revealed a Transfer Certification Statement for 10/16/15 with a suspected diagnosis of "dementia". The risks of transfer are listed as "MVC". The benefits of transfer were listed as "Specialized Care".

B. On 10/29/15 at 1545, the Emergency Department Manager reviewed the clinical records for Patient #2 and #3 and confirmed the findings of no documentation of the risk/benefits of transfer pertinent to the patient's diagnosis.