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Based on clinical record review and interview, it was determined the physician failed to countersign the "Authorization/Consent for Transfer" form for four (#1, #3, #7 and #9) of nine (#1, #3, #6, #7, #9, #10, #11, #14 and #15) patients transferred to another facility. The failed practice did not ensure the physician agreed with the risks and benefits of the transfer and had the potential to affect all patients transferred from the facility to another facility. The findings follow:

A. Review Patient #1, #3, #7 and #9's clinical records on 11/14/12 revealed there was no evidence of a physician countersignature on the "Authorization/Consent for Transfer" forms.

B. The findings were confirmed in an interview with the President/Chief Executing Officer on 11/14/12 at 0950.





Based on clinical record review and interview, it was determined the designated Qualified Medical Personnel (Registered Nurse) failed to consult with a physician before transferring the patient to another facility for three (#3, #9 and #11) of nine (#1, #3, #6, #7, #9, #10, #11, #14 and #15) patients. The failed practice did not ensure a physician determined the disposition of the patients and had the potential to affect all patients being seen by the Qualified Medical Personnel and transferred to another facility. The findings follow:

A. Review of Patient #3's "Medical/Psychiatric Screening Exam" form revealed a Telephone Order to transfer the patient to another facility from an Advanced Practice Nurse/Physician. It could not be determined if the Registered Nurse received the order to transfer the patient from the Advanced Practice Nurse or from the physician.

B. Review of Patient #9's "Medical/Psychiatric Screening Exam" form revealed a Telephone Order to transfer the patient to another facility from an Advanced Practice Nurse. There was no evidence the physician was notified to determine the disposition of the patient.

C. Review of Patient #11's clinical record revealed there was no evidence of a "Medical/Psychiatric Screening Exam" form. Review of the "Authorization/Consent for Transfer" form revealed an Advanced Practice Nurse was notified for consent to transfer. There was no evidence the physician was notified to determine the disposition of the patient.

D. The findings were confirmed in an interview with the President/Chief Executive Officer on 11/14/12 at 0950.