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Based on record review and staff interview; the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).

Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for one of five medical records of transferred patients reviewed (Patient #10). A total of 20 medical records were reviewed.

Findings include:

Review of the medical record for Patient #10 revealed an arrival date of 12/13/22 at 9:31 PM to the emergency department. The medical record contained documentation the patient had acute cystitis with hematuria and had a history of a kidney/pancreas transplant. The medical record contained documentation the patient was transferred to the transplant facility on 12/14/22 at 12:40 PM by lifeflight per the patient's request due to the potential for transplant complications. The medical record lacked documentation of a transfer document that listed the risks and benefits of the transfer signed by the physician.

On 04/05/23 at 3:07 PM, Staff C verified the transfer documents were not in the medical record for Patient #10.