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Based on observation, record review, and interview, the facility failed to indicate the risks and benefits of transfers writing in a signed physician certification on 21 of 707 Memorandums of Transfer (MOTs) for October through December of 2022.


Findings:
Memorandum of Transfer (MOT)'s for both the Emergency Department (ED) and inpatient units for October through December of 2022 consisting of 707 records were reviewed.

During October 2022, there were a total of 224 MOT's. Of the 224, 6 had incomplete information for the physician's certification.

During November 2022, there were a total of 214 MOT's. Of the 214, 5 had incomplete information "Risks or Benefits" information for the physician's certification and 1 of the 214 had a physician's certification that was unsigned.

During the month of December 2022, there were a total of 269 MOT's. Of the 269 MOT's, 9 had missing information for the physician's certification. Of the total 707 records reviewed there were 5 were missing the "Risks" to the patient involved if transfer was to take place information for the physician's certification, 3 were missing the "Benefits" to the patient if transferred information for the physician's certification, 12 were missing both the "Risks and Benefits" to the patient if transferred for the physician's certification, and 1 physician's certification was without a signature.

On the afternoon of January 3, 2023, information was given to Staff #16 and #17 to verify that of the 707 records reviewed for October through December of 2022, there were 20 were missing the Risks and/or Benefits information for the physician's certification and 1 without a signed physician certification. Staff #16 replied, "Did you notice a pattern for them? Was there one particular practitioner that it was happening with?" The response was, "I will let you look at them to identify if there is a pattern or not."