HospitalInspections.org

Based on medical record review, document review and interview in one (1) of ten (10) medical records (MR) reviewed, the facility did not follow its policy for ocular care for the patient during anesthesia and did not identify potential anesthesia problems.

Findings:
Review of medical record for patient #1 identified this 35 years old patient who underwent a surgical procedure at the Ambulatory Surgical Department of the facility on 06/15/2018. After the procedure, patient complained of blurry vision and "'grittiness'" in the eyes. Patient was evaluated by the Gynecologist and referred to an Ophthalmologist for further evaluation.
On 06/17/18, the Anesthesiologist documented that patient was diagnosed with "Exposure Keratopathy s/p D and E on 06/15 with GA/MAC anesthesia."


Per interview of Staff E ,Anesthesiologist on 10/09/2018, 10:57 AM, she stated that the patient did not have general anesthesia, but deep sedation. Staff E was asked to discuss patient's eye care in relationship to general anesthesia and deep sedation. Staff E stated that prior to general anesthesia, patient's eyes are lubricated, and then closed. She continued, "deep sedation is used for a short procedure prior to which, patients' eyes are shut, and not taped." Staff E said "there was no need to lubricate or close patient's eyes."

Review of "Ocular Care During Anesthesia" policy, Reviewed 06/17 revealed that "Lubrifresh ointment should be used in all cases of general anesthesia, and all deep sedation cases > 30 minutes duration."

Review of the patient's anesthesia record revealed that the anesthesia time is documented as follows:
Start: 06/15/2018 10:43
Finish: 06/15/2018 11:26
Total: 00:43"

These findings were brought to the attention of Staff A, Director of Nursing; Staff C, PSA Regulatory Affairs, and other administrative personnel on 10/10/18 at approximately 4:00 PM.