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Based on facility policy review, medical record review and staff interview, registered nursing staff failed to evaluate and discharge patients from the facility's recovery area according to facility policy after receiving an anesthetic medication in 2 of 6 sampled patients receiving anesthesia (Patient #4,6).

Findings include:

A review on 03/07/2012 of the facility policy and procedure "Discharge Guidelines From PACU (Post Anesthesia Care Unit)" (revised 02/2011) revealed "1..All patients receiving an anesthetic who come to PACU will be evaluated on an individual basis and will be discharged when meeting the discharge criteria or by the order of a physician. 2...A score of 9 or greater using the modified Aldrete Scoring System will be required for discharge from PACU without a direct order. A score of less than 9 will need a physician's discharge with a written order. 10..The Discharge Assessment should indicate that the discharge criteria have been met, or if not met, that patient is discharged by a physician."

A review on 03/07/2012 of the facility policy and procedure "Post Anesthetic Numeric Scoring System" (revised 02/2011) revealed "2..The patient's discharge evaluation will be completed prior to discharge and a score of 9 or greater will be required for discharge without a direct order. A score of less than 9 will require a physician's discharge."

1. An open medical record review on 03/07/2012 for patient #4 a 50 year old female, revealed that the patient was admitted to the hospital's behavioral health unit on 01/15/2012 with a diagnosis of "Bipolar Disorder NOS". The review revealed that the patient received ECT (Electroconvulsive Therapy) on 02/10/2012 with documented "General" anesthetics administered. The documentation revealed that the patient was placed on the hospital's PACU on 02/10/2012 from 0625 through 0655. The documentation revealed that the patient was documented as discharged from the PACU at 0655 with a total modified "Aldrete" score of "5" with no documentation of a physician discharge for the patient. The patient was discharged with a score of less than 9 back to the hospital's behavioral health unit.

An interview on 03/07/2012 at 1440 with the hospital's PACU Director revealed that the patient's should have a score of 9 or greater or have a physician discharge in order to leave the PACU after having general anesthesia administered. The interview further revealed that patient #4 did receive general anesthesia and was discharged from the PACU against the facility's policy guidelines.

2. A closed medical record review on 03/07/2012 for patient #6 a 39 year old female, revealed that the patient was admitted to the hospital's behavioral health unit on 08/13/2011 and discharged from the facility on 08/25/2011 with a diagnosis of "Mood Disorder". The review revealed that the patient received ECT (Electroconvulsive Therapy) on 08/15/2011 with documented "General" anesthetics administered. The documentation revealed that the patient was placed on the hospital's PACU on 08/15/2011 from 0708 through 0800. The documentation revealed that the patient was documented as being discharged from the PACU at 0800 with a total modified "Aldrete" score of "8" with no documentation of a physician discharge for the patient. The patient was discharged with a score of less than 9 back to the hospital's behavioral health unit.

An interview on 03/07/2012 at 1440 with the hospital's PACU Director revealed that the patient's should have a score of 9 or greater or have a physician discharge in order to leave the PACU after having general anesthesia administered. The interview further revealed that patient #6 did receive general anesthesia and was discharged from the PACU against the facility's policy guidelines.


Reference NC00079026.