HospitalInspections.org

Based on record review of medical records and policy and procedure and staff interview, the facility failed to ensure a physician examined 4 of 6 surgical patients (Patients 22, 24, 31 & 32) 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 Fiscal Year 2021 ending June 2022 was 126.

Findings are:

A. Review of Patient 22's medical record revealed the patient had a colonoscopy (a procedure to look at the inside of the colon and rectum) under Monitored Anesthesia Care (MAC) with sedation on 6/13/22. The physician electronically signed the section, "Pre-op risk evaluation by Physician immediately prior to surgery" on 7/11/22 at 1:26 PM with the fields below blank and not checked off:
-Heart and lungs have been assessed
-H&P reviewed with following changes notes
-Vital signs noted
There was no evidence of date or time immediately prior to surgery to ensure the examination took place immediately before surgery (procedure start time 12:43 PM on 6/13/22).

Review of Patient 24's medical record revealed the patient had an upper endoscopy (a procedure to look at the inside of the inner lining of the upper digestive tract (the esophagus, stomach, and duodenum, which is the first part of the small intestine) under Monitored Anesthesia Care (MAC) on 3/28/22. The physician signed the section, "Pre-op risk evaluation by Physician immediately prior to surgery" on 3/28/22 with the fields below checked off:
-Heart and lungs have been assessed
-H&P reviewed with following changes notes
-Vital signs noted
There was no evidence of time to ensure the examination took place immediately before surgery (procedure start time 10:11 AM on 3/28/22).

-Review of Patient 31's medical record revealed the patient had a colonoscopy (a procedure to look at the inside of the colon and rectum) under Monitored Anesthesia Care (MAC) with sedation on 7/25/22. The physician signed the section "Pre-op risk evaluation by Physician immediately prior to surgery" on 7/25/22 with the fields below checked off:
-Heart and lungs have been assessed
-H&P reviewed with following changes notes
-Vital signs noted
There was no evidence of time to ensure the examination took place immediately before surgery (procedure start time 8:21 AM on 7/25/22).

-Review of Patient 32's medical record revealed the patient had a colonoscopy (a procedure to look at the inside of the colon and rectum) under Monitored Anesthesia Care (MAC) with sedation on 4/11/22. The physician signed but failed to date or time the "Pre-op risk evaluation by Physician immediately prior to surgery" with the fields below checked off:
-Heart and lungs have been assessed
-H&P reviewed with following changes notes
-Vital signs noted
There was no evidence of date or time to ensure the examination took place immediately before surgery (procedure start time 3:00 PM on 4/11/22).

B. Interview with the Chief Nursing Officer (CNO) on 8/31/22 at 1:30 PM confirmed that policy "Anesthesia Care of Surgical Patients" stated under #4, "In pre-anesthesia management the responsible licensed practitioner must evaluate individuals who are to go under procedures requiring anesthesia, in regard to previous drug history, other anesthesia experiences and potential anesthetic problems, and/or review the pre-anesthesia experiences and potential anesthetic problems. The responsible licensed practitioner must sign the anesthesia record on the day of the surgery." CNO also confirmed 4 of 6 surgical patients lacked evidence of physician evaluation for the risk of the procedure immediately before surgery and confirmed the above medical records lacked a time of the assessment by the surgeon ensuring completion immediately before surgery.