HospitalInspections.org

Based on interviews, medical record reviews, and review of facility policy and procedure it was determined, the facility failed to ensure medical record (MR)# 1 had documented informed consent for the type of anesthesia used during MR# 1's procedure. This affected 1 of 5 MRs reviewed.

The findings include:

Policy and Procedure, "Assessment of Patients, Anesthesiology" revised 3/26/03, "4. Procedure: 4.1 Preanesthetic assessment ... 4.1.3.4. Patient education and the opportunity to ask questions or express concerns about the planned intervention. ... 4.1.10. Informed consent for the anesthesia ... shall be obtained and documented. 4.1.11.1. ... The planned anesthetic technique based on the patient's preanesthetic assessment, planned procedure ... and patient preference. ... 4.1.12. The responsible anesthesiologist shall verify that the above has been properly performed and documented in the patient record."

The Preanesthesia Evaluation dated 5/6/10 for MR# 1 documented on 5/6/10 by the CRNA (Certified Registered Nurse Anesthetist) revealed he had discussed GETA (general endotracheal anesthesia) and plan for GA (general anesthesia) and questions were answered. The Preanesthesia Evaluation conducted on 5/7/10 by the attending Anesthesiologist revealed, "Plan: GETA ...".

The Neurosurgery Operation Note dated 5/7/10 revealed, "Anesthesia: Local anesthetic by Anesthesia ... Description of Procedure: While supine on the operating table, she was heavily sedated. ... Lidocaine and epinephrine was injected into the skin ... ."

The Anesthesia Record dated 5/7/10 revealed, "Other Case Data- Technique MAC (Monitored Anesthesia Care)." Not the GA as the Preanesthesia Evaluation of 5/7/10 had documented.

There was no documentation the patient and family were informed of the change from GA to MAC anesthesia.