HospitalInspections.org

The hospital failed to ensure that medical records are complete as evidenced by:

In 4 of 16 records reviewed patients ((#3, 4, 5, and 6) were transferred from Southern Maryland Hospital to another hospital but the explanation of the patient's specific risks and benefits associated with that transfer were not found documented in the medical record. The hospital transfer form includes the language "based upon the reasonable risk benefits, as explained to the patient and documented on the chart, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risk, if any, to the individual's medical condition." However, despite the transfer form language "as explained to the patient and documented on the chart " the documentation of the specific risks and benefits associated with each transfer was not found documented in the 4 medical records for patient #3, 4, 5, and 6.