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JOHNSON CITY MEDICAL CENTER 400 N STATE OF FRANKLIN RD JOHNSON CITY, TN 37604 March 1, 2017
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility policy review, record review, and interview, the facility failed to obtain a certification of the risk and benefits of a transfer and failed to obtain a signed informed consent for transfer for one patient (#22) of 34 patients reviewed.

The findings included:

Review of facility policy EMERGENCY MEDICAL TREATMENT AND PATIENT TRANSFER effective date 8/15/14 revealed "...Prior to transfer, the physician must inform the patient or legal representative of the need for transfer and the risks and benefits of transfer and of refusal to consent to transfer...the physician shall take reasonable steps to obtain the patient's or legal representative's written consent to transfer or refusal to consent to transfer by having the patient or the patient's legal representative complete and sign Section II of the Transfer Authorization Form..." Further review of the policy revealed "...The physician must also complete...the other physician-required sections of the Transfer Authorization Form..." Further review of the policy revealed "...In order to verify and document appropriate transfers the following forms must be completed...Transfer Authorization Form...Completed for transfer to Acute Care facility or psychiatric facility. The white copy remains in the medical record and the carbon copy is sent with the patient..."

Review of the medical record for Patient #22 from Hospital #2 revealed the patient was admitted to the facility on [DATE] at 12:14 PM with complaint of injuring right leg during a fall at home. Further review of the medical record revealed "...right closed complex proximal tibia metaphyseal fracture above old plate/distal malunion [a complicated fracture of the lower leg above a previous surgically repaired fracture] and osteoporotic [weakened, brittle, fragile] appearing bone..." Further review of the medical record revealed "...She will need fixation of the tibia but this is a complex situation and may require removal of previous hardware and very long plate or nail. I discussed this situation with the patient. I discussed her case with...ortho-traumatologist in Kingsport who has agreed to accept her and manage this complex fracture. We will proceed with ER [emergency room ] to ER transfer..." Further review of the medical record of an ED [Emergency Department] Discharge Disposition note dated 1/8/17 at 3:39 PM revealed "...PT [patient] TO [Hospital #5] FOR ORTHO..." Further review of the medical record revealed no Transfer Authorization Form, no written certification the patient was informed of the risk and benefits of the transfer, and no signed informed consent by the patient or their legal representative.

Review of the medical record for Patient #22 from Hospital #5 revealed the patient was admitted to this facility on 1/8/17 with diagnosis of Closed Fracture of Right Tibia and Fibula (a fracture of both bones of the lower leg). Review of the History and Physical dated 1/8/17 revealed "...was transferred from [Hospital #2]..." Review of the Discharge Summary dated 1/11/17 revealed "...She had an uneventful open reduction internal fixation [surgical repair of a fracture] procedure of the right tibia/fibula...has otherwise done well and is stable for transfer to rehab facility..."

Interview with the Corporate Risk Manager from Hospital #2 on 2/27/17 at 3:30 PM, in the Risk Manager's office, confirmed the Transfer Authorization Form was used by the facility to document informed consent for transfer and to document the physician certification of the benefits and risks of transfers. Further interview confirmed Patient #22's medical record did not contain a Transfer Authorization Form and the facility failed to follow facility policy.