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Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the Physician and Nurses Notes were complete by failing to document assessment and re-assessment of a patient's condition prior to surgery.(MR1)


Findings include:

On August 18, 2021 review of facility policy Interdisciplinary Documentation and Charting, last revised January 6, 2021, revealed, "Policy. Purpose: To establish a consistent approach for documenting clinical data utilizing e-Health and the Clinical Practice Model framework ... B. Charting Clinical Data (General Information): 1. Patient data/Clinical information is to be recorded in e-Health. a. In real-time or as close to real-time as possible. b. As often as the patient's condition warrants to maximize communication between caregivers ... (a) A comprehensive examination/assessment (Head-to-Toe Assessment) of the patient will be performed and documented on the PCS upon admission by Nursing. ... ."

During interview with EMP1 on August 18, 2021, EMP1 stated, "When I assisted the patient from the chair to the scale for a weight, and back to the chair, they became dyspneic and sweaty. Patient stated that they had been having that issue for a couple days prior to coming in." EMP1 confirmed they found the patient's lung sounds were auscultated and found to have wheezing, in addition to a cough and some leg edema. EMP1 states they reported these findings immediately to EMP2. EMP1 states at that time EMP2 requested a Walking Test. EMP1 states during the Walking Test the patient's SATs went as low as 84%, the assessment was reviewed with EMP2.

An interview was conducted on August 18, 2021 with EMP3. EMP3 confirmed all patients are to receive a Head-to-Toe Pre-op assessment prior to surgery, in which an RN is to auscultate the lungs with a stethoscope and do a full body assessment and document it.

Additional medical records were requested and reviewed. On August 18, 2021 review of MR2 and MR3 revealed that lung auscultation sounds had been documented in the Head-to-Toe assessment by staff according to policy.

MR1 revealed SBAR Nursing note signed by EMP1 on June 17, 2021 8:04 AM. "Pt with DOE (dyspnea on exertion) and wheezing walking from Room 13 to Room 14. Pt reports SOB (shortness of breath) started Tuesday this week, which patient thought related to anxiety. No Echo pre-op. MD notified, RN to perform O2 walk study. Addendum: O2 walk study performed- Pox 84% on RA.

MR1 lacked documented evidence that EMP1 performed auscultation of lung sounds in the Head-to-Toe Assessment.

An interview with EMP4 on August 18, 2021 confirmed MR1 failed to have documentation of lung sounds when the patient exhibited shortness of breath.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to follow up on potential anesthesia problems related to obtaining Specialty Consults prior to day of surgery, and failed to document patient assessments and/or re-assessments. (MR1)



Findings include:

On August 18, 2021 review of facility policy Standards of Anesthesia Care, effective January 28, 2021. "A. Surgical Anesthesia: 1. Pre-anesthesia evaluation and preparation by a responsible physician requires that he/she: a. Review the paper chart and electronic medical record prepared and updated by the Perioperative Surgical Home (PSH) as per protocols established with the PSH by the Department of Anesthesia. This includes an interview conducted via phone with the PSH Registered Nurse, all pertinent patient information and test results. PSH protocols determine which patients who meet certain criteria and are at a low risk for surgical care are fast tracked such that an Anesthesiologist will review the information on the day of surgery. ... f. Within forty-eight (48) hours immediately prior to any procedure requiring anesthesia services, the anesthesiologist performs and documents a focused evaluation of the patient, which includes the following at a minimum: 1) Interview of the patient, if possible, given the patient's condition; 2) Review of the medical and anesthesia history, drug and allergy history; 3) Documented focused examination of the patient including an airway and heart and lung examination. ... ."

On August 18, 2021 review of facility policy Patient Admission, Discharge, Transfer (ADT) Policy Lancaster General Hospital Ambulatory Surgical Facility (LGHASF), effective May 13, 2021. "Policy. Purpose: The policy is to identify the admitting process, appropriate candidates for surgery or procedures, discharge and transfer functions in Lancaster General Hospital Ambulatory Surgical Facility (LGHASF) ... 8. Admission Requirements: b. Preadmission health conditions are adequately controlled and are such that the performance of the surgery or procedure in the ASF, rather than a hospital setting, does not pose an increased risk to the patient. ... ."


MR1 History & Physical performed on June 4, 2021, revealed, "... Assessment and Plan: ... I don't see previous Echo. EKG today seems stable. ... Pt Instructions: Recommend to have Cardiology clearance. ... ."


MR1 Pre-Anesthetic Evaluation: Assessment/Plan signed by EMP2 on June 17, 2021 at 8:31 AM. "Patient with dyspnea that started 2 days ago, lower extremity edema, and walking pulse ox in Preop that dropped to 84%, and patient with visible shortness of breath. Patient has <4METS and an abnormal EKG in addition to dyspnea but did not undergo any further testing preoperatively. ... Case will be rescheduled. Patient needs to see a Cardiologist and have an appropriate preoperative evaluation prior to a general anesthetic ... ."



An interview was conducted on August 18, 2021 with EMP2. EMP2 confirmed that the decision to cancel the surgery was not only due to the patient's response to the Walk Test but that the patient had not been seen by a Cardiologist prior to coming in for surgery, as advised during patient's pre-exam. EMP2 confirmed they spent greater than a half hour in the room with patient and family examining and explaining everything. EMP2 stated during discussion patient was at rest and O2 Sat was adequate, patient was not in apparent distress which did not raise a concern for emergency transport.


MR1 lacked documented evidence that EMP2 examined the patient post Walk Test, or that the O2 Sat and other vital signs were reassessed prior to discharge.


An interview was conducted with EMP1. "The determination of need to cancel a case due to patient condition is based on the anesthesia assessment on day of surgery and the urgency of the planned procedure. We do not have a policy with specific clinical parameters."