HospitalInspections.org

Based on record reivew, the provider failed to ensure patients received care in a safe setting. Specifically, unique identifiers of equipment used during surgical procedures was not recorded in the patient record.
Findings:
Medical records for patients who had surgical procedures were reviewed during a survey on 7/24-25/12. The medical records failed to identify the specific equipment, by serial number or other unique identifier, used during surgical procedures. The equipment included electrosurgical systems and endoscopes.
The medical record for a patient who had sugery on 7/25/12 was reviewed. The record contained information regarding the settings of the electrosurgical equipment used during the procedure. The area in the record for recording the equipment serial number was blank.
Medical records for 2 patients who had endoscopic procedures on 7/25/12 was reviewed. The records contained information regarding the endoscopes used during the procedures. The area for recording the endoscope serial number was blank.
The Association of PeriOperative Nurses (AORN) establishes standards for perioperative services. AORN states the documentation of details, including identification numbers for electrosurgical and endoscopic equipment, is necessary for the investigation of adverse events.

Based on interview and record review the provider failed to ensure a medical history and physical (H&P) examination was completed no more than 30 days before surgery.

Findings:

Open medical records for patients who were in the peri-operative area were reviewed during a survey conducted on 7/24-25/12. The H&P examinations for 4 of 4 patients, who were waiting for surgery or were in the post anesthesia care unit, were reveiwed. The H&Ps contained within the open records did not identify the date of the examination.

Nursing staff in the peri-operative area were interviewed on 7/25/12 at 10 am regarding the H&P. Nursing staff was not able to identify the date the H&P was performed.

Based on interview and record review, the provider failed to ensure a postanesthesia evaluation was completed and documented for each patient who received anesthesia.
Findings:
Anesthesia records for patients who had been discharged were reviewed during a survey conducted on 7/24-25/12. The anesthesia evaluations for 8 of 8 patients were either not documented, or were incomplete. Incomplete documentation failed to include information regarding the patient's cardiovascular and respiratory function, mental status, temperature, pain, nausea and vomiting, and postoperative hydration.
A nurse caring for a post operative patient was interviewed on 7/24/12 at 12:30 p.m. regarding the postanesthesia evaluations. The nurse stated that postanesthesia evaluations were not always completed and documented.