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SUMMERS COUNTY ARH HOSPITAL
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Tag No.: C0322
Based on record review and interview the facility failed to ensure patients were evaluated for proper anesthesia recovery prior to discharge from the hospital by a qualified practitioner for five (5) of five (5) cases reviewed (patients #1, 2, 3, 4 and 5). This has the potential for patients to be discharged without proper assessment for anesthesia complications.
Findings include:
1. The Nurse Manager of the Operating Room was interviewed on 2/6/2012 at about 11 a.m. She stated there had been six (6) surgical cases requiring anesthesia services during the month of January 2012. A total of five (5) of those cases were reviewed.
2. Review of the medical record for patient #1 revealed the patient received a laparoscopic cholecystectomy on 1/25/2012 with general anesthesia by the Certified Registered Nurse Anesthetist (CRNA). The patient was discharged to home the same day. There was no post-anesthesia evaluation documented by the CRNA.
3. Review of the medical record for patient #2 revealed the patient received a laparoscopic cholecystectomy on 1/25/2012 with general anesthesia by the CRNA. The patient was discharged to home the same day. There was no post-anesthesia evaluation documented by the CRNA.
4. Review of the medical record for patient #3 revealed the patient received a laparoscopic cholecystectomy on 1/11/2012 with general anesthesia by the CRNA. The patient was discharged to home the same day. There was no post-anesthesia evaluation documented by the CRNA.
5. Review of the medical record for patient #4 revealed the patient received surgery on a ganglion cyst with monitored anesthesia care (MAC) by the CRNA. The patient was discharged to home the same day. There was no post-anesthesia evaluation documented by the CRNA.
6. Review of the medical record for patient #5 revealed the patient received surgery on a skin lesion with MAC by the CRNA. There was no post-anesthesia evaluation documented by the CRNA.
7. The Nurse Manager of the OR was interviewed at 3 p.m. on 2/6/2012. She concurred with the findings in the medical records.