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DUNCAN REGIONAL HOSPITAL, INC
PATIENT RIGHTS: INFORMED CONSENT
Tag No.: A0131
Based on record review and interview, the hospital failed to ensure patient involvement in care decision for one (Patient #2) of ten patients.
This failed practice has the likelihood to result in patients not being aware of their options for care, thereby impeding on their rights.
A review of a policy titled "Transfer Policy and Procedure" read in part, "Internal procedures for all outgoioing transfers: the transferring physician is to complete sectioins 1-7 on the Physician Assessment/Certification and Transfer Form. Physician signature and date are required on the bottom of the form...Complete the licensed nurse portion of the...Patient Transfer Form...keep the original transfer sheet with the patient's records."
A review of the medical record for Patient #2 showed no transfer form.
On 08/24/20 at approximately 12:30 PM, Staff I reviewed the medical record for Patient #2 and stated:
1. There was no transfer form found in the chart and there should have been.
2. Transfer forms served as patients' consent to transfer and documented patients' understanding of why they were transferring.