HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to ensure that 6 of 14 discharged surgical patient records (Patients 7, 9, 10, 11, 17 and 21) contained evidence that the physicians completed and documented an examination of the patient immediately before surgery. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 5/21/17 to 3/2/18 was 644.

Findings are:

A. Review of Patient 7's medical record (on 4/18/18 at 8:00 AM) revealed the patient had an incision and drainage of an abdominal wall abscess (a clinical lancing [cut] to release built up pus or fluid under the skin) on 7/17/17. Patient 7's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of Patient 9's medical record (on 4/18/18 at 9:15 AM) revealed the patient had a right knee irrigation and debridement (methods used to clean a wound) with open arthrotomy (surgical incision into a joint) and synovectomy (removal of synovial tissue surrounding the joint) on 9/27/17. Patient 9's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

C. Review of Patient 10's medical record (on 4/18/18 at 9:45 AM) revealed the patient had placement of bilateral thoracostomy tubes (tube inserted through an opening in the chest wall with the use of suction used to drain fluid or blood or to reexpand the lung) on 5/24/17. Patient 10's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

D. Review of Patient 11's medical record (on 4/18/18 at 10:10 AM) revealed the patient had right hip surgery on 5/21/17. Patient 11's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

E. Review of Patient 17's medical record on (4/18/18 at 1:50 PM) revealed the patient had a left breast biopsy on 1/10/18. Patient 17's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

F. Review of Patient 21's medical record (on 4/18/18 at 2:40 PM) revealed the patient had a colonoscopy on 1/31/18. Patient 21's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

G. Review of the facility policy and procedure titled "Preoperative History & Physical" (dated 11/2007) revealed "The MD will complete the PRE-OPERATIVE HISTORY AND PHYSICAL EXAMINATION form that is on the chart before the surgical procedure is done. The form must be signed with a legible signature and dated and timed."

H. Interview with the Health Information Technician (HIT) Lead (on 4/19/18 at 3:10 PM) confirmed the above medical records lack the documentation of the patient examinations by the physicians immediately before surgery to evaluate the risk of the procedure to be performed.