Medical City Alliance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure the written informed consent of a patient for transfer, in that,

A) 1 of 10 patient transfer (Patient #5) records did not have a signed by the patient, written informed consent for the transfer to another hospital on [DATE]; and

B) 2 of 10 patient transfers (Patient #3 and #4) were issued by telephone order and the physician did not countersign the certification/authorization the transfer timely.

Findings included

A) Patient #5's records did not have a signed by the patient, written informed consent for the transfer to another hospital on [DATE].

During an interview on 4/17/19 ending at 12:53 PM, Personnel #1 reviewed the MOT's and confirmed Patient #5 did not sign his MOT (Memorandum of Transfer) to document his agreement with the transfer.

The facility's undated, Memorandum of Transfer training document required, MUST FILL OUT ALL PATIENT INFORMATION...Patient Consent...PERSON SIGNING FOR SIGNATURE MUST MARK THE BOX THAT ACKNOWLEDGES THE RISKS AND BENEFITS, AND MARK AGREE/REFUSE REQUEST...Signature of Patient...MUST HAVE SIGNATURE...must have nursing supervisor review for completion prior to patient leaving facility...

B) Patient #3's Memorandum of Transfer (MOT) physician signature line reflected a verbal order by the physician. The physician did not countersign the MOT timely.

Patient #3's Memorandum of Transfer (MOT) physician signature line reflected a verbal order by the physician. The physician did not countersign the MOT timely.

During an interview on 4/17/19 ending at 1:43 PM, Personnel #1 reviewed the patient's MOTs and confirmed Patient #3's and #4's were not signed by the physician.

The facility's undated, Memorandum of Transfer training document required, MUST FILL OUT ALL PATIENT INFORMATION...Physician Certification...MARK ALL THAT APPLY...Signature of Transferring Physician...PHYSICIAN MUST SIGN & DATE...must have nursing supervisor review for completion prior to patient leaving facility...

The facility's 2/21/19 Medical Staff Rules and Regulations required, hospital's procedures for patient transfers to other facilities must be followed...all verbal/telephone orders are to be signed, dated, and timed...on their next visit, but within 48 hours...

Based on record review and interview, the faility failed to ensure a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient be forwarded to the receiving physician and receiving hospital with the patient for 2 of 10 transfer patients (Patient #9 and #10), in that,

Patient #9 and #10 were transferred due to a need for CABG (Coronary Artery Bypass Graft). The a copy of the available and relevant medical records for continuing care of the patient were not sent to the receiving physician and hospital with the patient.

Findings included

Patient #9's record did not reflect a copy of the available and relevant medical records were not sent with the patient.

Patient #9's MOT reflected, Coronary Artery Disease...(the following are Marked) STABLE...EMERGENCY Transfer...specialized treatment or care...invasive procedure/testing not available here...other: CABG (Coronary Artery Bypass Graft)...Attachments: (the following are Marked) nursing progress notes... No other attachments were marked as sent with the transfer including X-rays, lab reports, H&P, physician progress notes, medication record, ABG's, EKGs, or Medication reconciliation form.

Patient #10's record did not reflect a copy of the available and relevant medical records were not sent with the patient.

Patient #10's MOT reflected, Multiple Vessel Disease...(the following are Marked) STABLE...EMERGENCY Transfer...specialized treatment or care...improve possibility of retaining life or limb...invasive procedure/testing not available here...other: CABG (Coronary Artery Bypass Graft)...Attachments: (the following are Marked) other: PAX (picture archiving and communication system for radiology)... No other attachments were marked as sent with the transfer including X-rays, lab reports, H&P, physician progress notes, nursing progress notes medication record, ABG's, EKGs, or Medication reconciliation form.

There was no nursing documentation found that other records were sent at the time of the transfer or after the transfer.

During an interview on 4/17/19 ending at 1:43 PM, Personnel #1 confirmed the medical records were not sent. If they need record, they know who to ask. Personnel #1 added, the sister hospital can see our records. Personnel #1 was asked if the ambulance can see the record. Personnel #1 stated, No.

The facility's undated, Memorandum of Transfer training document required, MUST FILL OUT ALL PATIENT INFORMATION...Transfer Attachments...MARK ALL ATTACHMENTS...Questions regarding medication reconciliation should be directed to...NAME OF PATIENT'S PRIMARY NURSE...must have nursing supervisor review for completion prior to patient leaving facility...