HospitalInspections.org

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Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure a physician examined the patient immediately before surgery for 3 of 10 inpatient surgical records (Patient's 12, 13 and 19) reviewed. This failed practice had the potential to affect all surgical inpatients of the CAH. Total surgical inpatients between 8/1/19 to 12/31/19 was 50.

Findings are:

A. Review of Patient 12's medical record (1/15/2020 at 9:30 AM) revealed the patient had an I&D (incision and drainage) of a left facial abscess (a confined collection of thick fluid caused by infection) on 12/4/19 at 12:48 PM. Review of the "Preoperative Evaluation" revealed the examination completed at 5:30 PM on 12/3/19; the evening before the surgery occurred. Review of the entire medical record lacked evidence of a physician examination of the patient immediately before the procedure.

-Review of Patient 13's medical record (1/15/2020 at 10 AM) revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder with a procedure that uses several small cuts instead of one large one) on 11/14/19 at 7:35 AM. Review of the "Preoperative Evaluation" revealed the examination completed on 11/3/19 at 1445 (2:45 PM); the afternoon before the surgery occurred. Review of the entire medical record lacked evidence of a physician examination of the patient immediately before the procedure.

-Review of Patient 19's medical record (1/15/2020 at 11 AM) revealed the patient had an ORIF (open reduction and internal fixation) Left hip fracture on 8/20/19 at 16:15 (4:15 PM). Review of the "Preoperative Evaluation" revealed the examination completed at 1315 (1:15 PM) on 8/20/19; three (3) hours before the surgery occurred. Review of the entire medical record lacked evidence of a physician examination of the patient immediately before the procedure.

B. Interview with the Clinical Informaticist (1/15/2020 at 4:30 PM) revealed the facility did not have a policy and procedure directly related to the preoperative evaluation and confirmed the above medical records preoperative evaluations are not completed immediately prior to the surgical procedures.