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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 of 7 (#1, #2, #4-#6, #9 and #10) of 10 (#1-#10) transferred patients. Failure to disclose the risks and benefits specific to the condition did not allow Patients #1, #2, #4-#6, #9 and #10 to make an informed decision regarding the need for the transfer. The failed practice was likely to affect Patients #1, #2, #4-#6, #9 and #10. Findings follow:

A. Patient #1 presented to Emergency Room on 06-25-16 with diagnosis of Mood Disorder, Agitation and Combative Behavior. Patient #1 was transferred to an inpatient psychiatric facility on 06-26-16. The Transfer Record dated 06-25-16 revealed:
Risks-Motor Vehicle Accident, Bad Weather
Benefits-Specialized Psychiatric Care

B. Patient #2 presented to the Emergency Room on 06-25-16 with diagnosis of Suicidal Ideation, Assaulted Mom. Patient #2 was transferred to an inpatient psychiatric facility on 06-25-16.
The Transfer Record dated 06-25-16 revealed:
Risks-accident en route
Benefits-psych (psychiatric) eval (evaluation) and treatment

C. Patient #4 presented to the Emergency Room on 12-09-15 with diagnosis of Major Depression. Patient #4 was transferred to an inpatient psychiatric facility on 12-09-15.
The Transfer Record dated 12-09-15 revealed:
Risks-Safety concerns
Benefits-evaluation and treatment

D. Patient #5 presented to the Emergency Room on 05-01-16 with diagnosis of Suicidal Ideation. Patient #5 was transferred to an inpatient psychiatric facility on 05-01-16.
The Transfer Record dated 05-01-16 revealed:
Risks-MVA (Motor Vehicle Accident) decompensation during transport
Benefits-higher level of care, inpatient admission for psychiatry services

E. Patient #6 presented to the Emergency Room on 05-26-16 with diagnosis of Suicidal Ideation. Patient #6 was transferred to an inpatient psychiatric facility on 05-26-16.
The Transfer Record dated 05-26-16 revealed:
Risks-Normal risks of ground travel
Benefits- Necessary evaluation and treatment

F. Patient #9 presented to the Emergency Room on 04-21-16 with diagnosis of Suicidal Ideation. Patient #9 was transferred to an inpatient psychiatric facility on 04-21-16.
The Transfer Record dated 04-21-16 revealed:
Risks-MVA with bodily harm and even death, run away
Benefits-inpatient treatment

G. Patient #10 presented to the Emergency Room on 05-09-16 with diagnosis of Suicidal Ideation. Patient #10 was transferred to an inpatient psychiatric facility on 05-09-16.
The Transfer Record dated 05-09-16 revealed:
Risks-Car accident
Benefits-psychiatric care.

H. On 06-28-16 at 1400 the Nursing Director Emergency Department and the Director of Accreditation verified the risks and benefits were not specific to the condition of the patients.