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Based on review of the facility's Medical Staff Rules and Regulations, facility policy review, medical record reviews, and interviews, the facility failed to obtain informed consent for a patient transfer and failed to obtain a physician's certificate identifying the reason for the transfer and the risks and benefits of the transfer for 3 patients (Patient #11, Patient #21, and Patient #25) of 34 sampled patients.

The findings included:

Refer to A2409.

Based on review of the facility's Medical Staff Rules and Regulations, facility policy review, medical record reviews, and interviews, the facility failed to obtain informed consent for a patient transfer and failed to obtain a physician's certificate identifying the reason for the transfer and the risks and benefits of the transfer for 3 patients (Patient #11, Patient #21, and Patient #25) of 34 sampled patients.

The findings included:

Review of the facility's Medical Staff Rules and Regulations dated 12/2014 revealed "...Upon transfer, the Emergency Department [ED] shall provide to the receiving facility a copy of...informed written consent or transfer certification..." All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer. The Emergency Department Physician must inform the patient (or patient's representative) of the risks and benefits of the proposed transfer..."

Review of the facility's policy titled Transfer of Patients and Clinical Records Policy dated 1/1/2007 revealed "...A Transfer Authorization Form is to be filled out on all transfers going from this facility to another acute care hospital. This form also obtains the patient's consent for the transfer (and refusal if the transfer is recommended but the patient refuses). All information must be filled out on this form...The original is to be kept with the medical record..."

Medical record review revealed Patient #11 presented by ambulance to the ED at Hospital A on 10/15/2020 at 7:46 PM and was diagnosed with a Left Hip Fracture. The patient was transferred by ambulance to Hospital C on 10/15/2020 at 11:12 PM. Continued review of the medical record revealed no documentation of a Transfer Authorization Form. Continued review revealed no documentation the patient or the patient's representative gave consent for the transfer or was informed of the risks and benefits of the transfer by the physician.

Review of medical records from Hospital C revealed Patient #11 was admitted there on 10/15/2020 with diagnosis of Left Hip Fracture. Continued review revealed the patient had an Open Reduction Internal Fixation of her Left Hip on 10/16/2020. Continued review revealed the patient was discharged on 10/21/2020.

Medical record review revealed Patient #21 presented to the ED at Hospital A on 8/1/2020 at 11:52 AM and was diagnosed with Fever and Crohn's Disease (chronic inflammatory bowel disease). The patient was transferred to Hospital D by ambulance on 8/1/2020 at 10:05 PM. Continued review of the medical record revealed no documentation of a Transfer Authorization Form. Continued review revealed no documentation the patient or the patient's representative gave consent for the transfer or was informed of the risks and benefits of the transfer by the physician.

Review of medical records from Hospital D revealed Patient #21 was admitted there on 10/15/2020 with diagnosis of Crohn's Disease and Left Gluteal Abscess. Continued review revealed the patient was discharged home on 10/21/2020.

Medical record review revealed Patient #25 presented to the ED at Hospital A on 7/15/2020 at 7:31 PM and was diagnosed with Internal Defibrillator (implanted medical device to help control heart rhythm) In Wrong Place. Continued review revealed the patient was transferred to Hospital B on 7/15/2020 at 11:15 PM. Continued review of the medical record revealed no documentation of a Transfer Authorization Form. Continued review revealed no documentation the patient or the patient's representative gave consent for the transfer or was informed of the risks and benefits of the transfer by the physician.

Review of medical records from Hospital B revealed Patient #25 was admitted there on 7/16/2020 with diagnosis of Displacement of Cardiac Electrode and Atrioventricular Block (delays or blockage of the electrical impulse of the heart). Continued review revealed the patient had a surgical procedure to reposition the cardiac electrode on 7/16/2020 and was discharged on 7/17/2020.

During an interview on 12/10/2020 at 12:30 PM, the ED Director stated it was the facility's policy to complete a Transfer Authorization Form for all patients who were transferred to another hospital. Continued interview confirmed there was no Transfer Authorization Form or consent for transfer in the medical records for Patient #11, Patient #21, and Patient #25. Continued interview confirmed was no documentation Patient #11, Patient #21, or Patient 25 or their representatives were informed of the risks and benefits of the transfer by the physician.