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Based on review of documentation and interviews with facility staff, the facility failed to complete Memorandum of Transfer forms as required by facility policy in 3 of 20 cases reviewed where a hospitalized patient developed a medical condition requiring transfer to an acute care hospital. In another 8 cases where a patient was transferred to an acute care hospital, the Memorandum of Transfer was not signed by a physician. This resulted in missing documentation required by facility policy when a patient was transferred which included a physician's certification which includes a summary of risks and benefits of transfer.

The findings were:

The facility policy entitled "Medical Emergencies" dated 7/16 reflected in part "Policy: El Paso Behavioral Health System will provide triage, basic first aid, basic life support, and notification to emergency services in the event of an unexpected illness or injury of a patient, visitor, staff member, applicant, prospective patient or passerby to the extent the equipment and expertise allow on site at the time of the event. Procedure ...4. Nursing, and/or medical staff, will determine the nature of the medical emergency and, if a patient of the hospital, contact the internal medicine group, the attending physician and/or the on call physician for medical orders. 5. If a life-threatening emergency exists, basic life support measures will be initiated and a 911 call placed to activate the Emergency Medical System ...B. A patient status report will be called to the Emergency Department of the receiving hospital. Once the medical emergency has been addressed, a Memorandum of Transfer will be prepared and forwarded at the first available opportunity."

The Transfer Agreement between Tenet Hospitals d/b/a Providence Memorial Hospital, Sierra Medical Center, and Sierra Providence East Medical Center and University Behavioral Health of El Paso dated 5/3/13 reflected in part "2. Responsibilities of the Transferring Facility. The Transferring Facility shall be responsible for performing or ensuring performance of the following ...p. Complete, execute, and forward a memorandum of transfer form, incorporated herein as Attachment 'A,' to the Receiving Facility for every patient who is transferred."

The facility policy entitled "Memorandum of Transfer" dated 7/16 reflected in part "Memorandum of Transfer: A Memorandum of Transfer must be completed for every patient transferred and must contain the following information ...a Certification signed by the transferring physician who includes a summary of the risks and medical benefits reasonably expected as a result of transfer (Document on the Memorandum of Transfer form)."

A sample of twenty patient records were reviewed where the patient was transferred to an acute care hospital. The patient records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form.

The medical record of patient # F1 contained a nurse's note dated 11/30/16 at 0605 that reflected in part "patient pacing on hallway, suddenly pt (patient) stopped screaming & fainting, falling down face to floor. Noted having a seizure lasting about 10 seconds. Pt unconscious, code blue team present. VS (vital signs) 130/80 - 89 - 90% RA (oxygen saturation 90% on room air), ventimask applied. Dr., staff # F11 with patient at this moment 911 is called PRN." At 0640 " Report is given to Alex RN to SMC (Sierra Medical Center) ER. "

The patient record of patient # F7 contained a nurse's note dated 10/25/16 at 2250 that reflected in part "Pt c/o (complained of) severe pain and swelling in his L (left) foot d/t (due to) gout attack. Pt was observed to have 1+ pitting edema @ L ankle w/discoloration. Pt requested to be taken WBAMC (William Beaumont Army Medical Center) ER for prednisone injection. Dr., staff # P12 contacted. Nursing supervisor contacted. Pt MOT to Sierra MC."

The patient record of patient # F17 contained a nurse's note dated 11/21/16 at 0546 that reflected in part "He did not attend groups because he slept all day due to stomach pain and vomiting. He was medication compliant with no adverse effects today. He was sent out via EMS life ambulance at 0140 for severe abdominal pain, severe emesis/nausea, weakness, hypoactive bowel sound, and the patient stating 'I can't take it anymore, I feel like I'm dying.' Report was previously called to Sierra Medical Center where patient was sent." At 11/21/16 0600 the nurse's note reflected in part "Sierra Medical Center informed me via phone that the patient will be admitted ...he had fluid in his abdomen from a draining abscess."

The medical records of patients # F6, F9, F10, F11, F15, F16, F20, and F22 who had been transferred to acute care hospitals contained Memorandum of Transfer forms where a physician had not signed the Physician Certification which reflected "Based upon the information available at the time of transfer, the medical benefits reasonable expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks of transfer to the patient and in the case of labor, the unborn child."

In an interview with the risk management director, staff # F2 on 1/24/17 at approximately 4:00 pm, staff # F2 agreed that the medical records of patients # F1, F7, and F17 did not contain a Memorandum of Transfer form and that the Memorandum of Transfer forms for patients # F6, F9, F10, F11, F15, F16, F20, and F22 were incomplete.