HospitalInspections.org

Based on interviews and medical record review, it was determined the facility staff failed to document patient complications and/or problems under anesthesia in the patient's medical chart for one (1) of three (3) medical records reviewed.

The findings include:

A review of the facility's policy "IHS Reporting and Response to Safety Events Policy", effective October 14, 2022, indicated in part "...Safety Event: An error/deviation (e.g. policy, procedure, process, practice or equipment failure) that reaches the patient and may or may not cause harm...reporting a safety event: Expectations of Team Members, 1. Safety event reporting is encouraged and expected to occur the day of the event or when it was detected to assure accurate recall of the circumstances and facts surrounding the incident...4. Document in the patient's medical record only the objective facts of the event...".

On August 26, 2024 at 12:55 PM, an interview was conducted with Staff Member #8. Staff Member #8 explained that during the MRI, Patient #1 began to move and when Staff Member #11 went into the room to assess the patient, Staff Member #11 noticed that the IV line that was administering propofol was "nicked" and the propofol was leaking out and not going into the patient. Staff Member #11 was able to administer the medication ketamine and Patient #1 fell back to sleep and was able to complete the MRI.

Staff Member #8 reviewed Patient #1's medical chart with the surveyor at the time of the interview and stated that this incident was not documented in Patient #1's medical record, but it should have been. Staff Member #8 also stated that the occurrence with Patient #1's IV line being "nicked" should have been reported as a safety event and should have been documented in Patient #1's medical record.

On August 26, 2024, a review of three (3) sampled patient medical records was conducted with Staff Member #3, #5, and #7. The surveyor confirmed the medical record for Patient #1 did not contain documentation of any issues or complications during an MRI procedure on 7/8/24 as required by facility policy.

The findings were discussed with Staff Members #1, #2, #4, #5, and #6 at the exit conference on August 26, 2024, at 3:00 PM.