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Based on medical record review and interview, the hospital failed to ensure the medical record was legible for one of four surgical patients reviewed (Patient 54), when the anesthesia documentation of the surgical procedure performed was written over and was difficult to read. This resulted the potential for inaccurate information regarding the surgical procedure performed.

Findings:

On 1/4/11, a review of Patient 54's medical record revealed Patient 54 had surgery on 1/1/11. The physician's History and Physical, dated 1/1/11, showed a pelvic ultrasound, done previously as an outpatient, had reported the patient to have a right ovarian cyst. However, review of the physician's Operative Record showed a subtotal abdominal hysterectomy (surgical removal of the uterus) and a left ovarian cystectomy (surgical removal of a cyst from the ovary) was performed.

Review of the Anesthesia Record, dated 1/1/11, showed the anesthesiologist, MD B, documented the surgery as a subtotal abdominal hysterectomy and "R" (right) ovarian hysterectomy. The "R" had been written over.

On 1/4/11 at 1540 hours, MD B was interviewed. The anesthesiologist was asked to review Patient 54's medical record. MD B stated he documented the operation as per the surgeon's preoperative diagnosis on the History and Physical form. MD B stated the surgery however was performed for a left ovarian cyst. The anesthesiologist stated at that time he wrote " L" (left) over the "R" The anesthesiologist stated the surgical procedure documented on his report was not legible.

Based on medical record review and interview, the hospital failed to ensure the physician documented full informed consent for one of four surgical patients reviewed (Patient 55). Prior to surgery, there was no documented evidence to show the patient was fully informed of the possible additional surgical procedures which might be necessary. In addition, when the additional surgeries were performed, there was no documentation to show the patient was apprised of the outcome. This resulted in the potential for the patient to not understand the treatment he had received.

Findings:

On 1/4/11, the medical record for Patient 55 was reviewed. The patient had emergency surgery on 1/1/11. The patient signed an informed consent for a "Right Revision of Axillary Femoral Artery Bypass." Further review of the Operative Report, dated 1/1/11, showed the surgery included: right brachial artery exposure (major artery in the arm), right axillary (under the arm) graft revision, intra-operative angiography (imaging to visualize the inside of the blood vessel during the surgery), a left femoral popliteal-greater-saphenous vein bypass (surgical rerouting of blood flow around the obstructed artery that supplies blood to the legs and feet), and distal thrombectomy (surgical removal of a blood clot from the lower end of the bypass). There was no documented evidence to show the "left femoral vein bypass, distal thrombectomy" was discussed with the patient prior to or after the surgery.

MD A, the surgeon for Patient 55, was interviewed on 1/4/11 at 0935 hours. MD A stated the patient had a right axillary to bilateral femoral artery bypass procedure and left femoral to below the knee popliteal bypass surgeries done a month ago. MD A stated the revision surgery performed on 1/1/11, was an emergency surgery to inspect the surgical condition of the axillary graft. All of the possible procedures that had been preformed had been discussed with the patient prior to the surgery. The surgeon stated the patient was informed after the surgery of exactly what procedures had been performed. MD A stated he was unable to locate documentation of the discussions with Patient 55 in the medical record.