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Based on observation, interview, and record review the facility failed to protect patient's rights in 1(#6) out of 8 (#1 through #8) patient records reviewed. The facility failed to ensure that informed consent had been completed and documented prior to the patient's transfer from the facility to a higher level of care.

This deficient practice had the likelihood to affect all patients of the hospital.

Findings included:

On June 27, 2019 at 3:00 p.m. an interview with Staff # 7 revealed two of the patient's children, listed on her advanced directive as qualified representatives, arrived prior to the patient's transfer from the hospital. Staff # 7 stated the family was informed the patient was being transferred, but neither she nor any other staff member ensured the patient's qualified representatives signed the consent to transfer, thereby agreeing to the transfer.

Review of the medical record revealed the "Consent to Transfer" section of the Memorandum of Transfer (MOT) was not signed by patient's qualified representatives or hospital staff.

Review of facility's policy "Memorandum of Transfer Completion," section II, subsection 4 states "The transferring physician will explain the risks and benefits of the transfer to the patient (Informed Consent). The patient (or qualified representative) will complete and sign patient consent to transfer completing Section B. Consent can be witnessed by any two staff members." Subsection 5 states "The nurse caring for the patient at the time of transfer is responsible for reviewing the MOT to assure that all appropriate portions are complete and accurate prior to transferring the patient." The facility staff failed to follow their own policy by not obtaining a signed and witnessed consent to transfer from neither the patient nor the qualified representative. The facility staff also failed to ensure the MOT was complete and accurate prior to the patient transferring.