HospitalInspections.org

Based on medical record review, review of Medical Staff Rules and Regulations and staff interview, the CAH (Critical Access Hospital) failed to ensure a physician examined 3 of 6 reviewed surgical patients (Patient's 1, 2 and 5) immediately before surgery to evaluate the risk of the procedure to be performed. This failed practice had the potential to affect all surgical patients of the CAH. Total number of surgical procedures for 2022 (January - December) was 291.

Findings are:

A. Review of Patient 1's medical record (8/23/23 at 8 AM) revealed the patient had a colonoscopy (an examination of the inside of your large intestine, which includes your colon, rectum and anus) under MAC (Monitored Anesthesia Care) on 3/30/23. Review of the entire medical record revealed a lack of evidence of an examination completed by a physician immediately before surgery (Surgery Time 1:35 PM) to evaluate the risk of the procedure performed.

-Review of Patient 2's medical record (8/23/23 at 9 AM) revealed the patient had Right foot 5 toenails excision (removal) under MAC on 3/21/23. Review of the entire medical record revealed a lack of evidence of an examination completed by a physician immediately before surgery (Surgery Time 8:23 AM) to evaluate the risk of the procedure performed.

-Review of Patient 5's medical record (8/23/23 at 10:25 AM) revealed the patient had a vaginal hysterectomy (uterus is surgically removed through the vagina) under general anesthesia ( patient receives medications for amnesia, analgesic, muscle paralysis and sedation) on 6/12/23. Review of the entire medical record revealed a lack of evidence of an examination completed by a physician immediately before surgery (Surgery Time 10:53 AM) to evaluate the risk of the procedure performed.

B. Review of the Medical Staff Rules and Regulations (Approved 6/21/2017) stated the following under Medical Records Required Content: "Medical records will conform to the Medical Staff Bylaws, Rules and Regulations, state hospital licensure regulations and standards set out in the Medicare regulations related to certification as a critical access hospital."

C. Interview with the OR (Operating Room) Director (8/23/23 at 11:30 AM) confirmed the above medical records lacked documentation of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.