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Based upon interview, medical record review and document review, the facility did not comply with all of the provisions for documenting the risks versus benefits of transfer on the physician certification for transfer. Please reference findings under Tag 2409.

Based on medical record review, policy review and interview, the risks and benefits associated with transfer to a higher level of care were not documented on the physician certification for transfer for 3 of 5 patients.

Findings Include:

Review on 1/6/16 of policy #24.0049.5 " Transfer for ED Patient " last revised 12/2015 revealed the risks and benefits (of transfer) will be assessed and documented on the transfer certificate.

Review of the transfer certificate dated 11/20/15 for Patient #1 revealed the section of the transfer certificate for physician attestation that the benefit of transfer outweigh the risk was not completed. In addition, the section for the documentation of risks and benefits of transfer notes only "determination of condition enroute".

Review of the transfer certificate dated 12/28/15 for Patient #2 revealed the section of the transfer certificate for physician attestation that the benefit of transfer outweigh the risks was not completed. In addition, the section for the documentation of risks and benefits of transfer was incomplete. Only the risks associated with the mode of transport were identified.

Review of the transfer certificate dated 12/31/15 for Patient #3 revealed the section for the documentation of risks and benefits of transfer was not completed.

Interview on 1/6/16 at 2:15 PM with Staff # 1 and Staff # 2 verified these findings.



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