HospitalInspections.org

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure that a physician examined the patient immediately before surgery to evaluate the risk of the planned procedure for 11 of 12 surgical medical records (7, 8, 9, 10, 11, 23, 24, 25, 26, 27 and 28) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of procedures performed at the CAH on a monthly basis is 20.

Findings are:

A. Review of Patient 7's medical record on 4/13/16 at 2:45 PM revealed the patient had a cesarean section (C-Section) on 3/1/16. Review of the Physician Orders Pre-Surgical Exam revealed a pre-printed statement that read: "The pre-operative H&P has been reviewed and the patient has been examined and is stable. I concur with the findings of the pre-operative H&P. Proceed with the surgery/procedure. There have been no significant changes since the completion of the pre-operative H&P." Review of the physician signature lacked evidence of an examination time ensuring it was completed immediately before surgery (8:24 AM).
-Review of Patient 8's medical record on 4/15/16 at 8:40 AM revealed the patient had a right total knee arthroplasty (a procedure for diagnosing and treating joint problems) on 2/25/16. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 3/2/16 (6 days after surgery) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 9's medical record on 4/15/16 at 9:00 AM revealed the patient had bilateral total knees on 3/17/16. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 10's medical record on 4/15/16 at 8:30 AM revealed the patient had a right total knee arthroplasty on 12/17/15. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 11's medical record on 4/15/16 at 8:45 AM revealed the patient had a left hip arthroplasty on 1/14/16. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 23's medical record on 4/13/16 at 1:25 PM revealed the patient had a laparoscopic cholecycsectomy (surgery to remove gallbladder) on 11/2/15. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 11/2/15 at 09:15 (AM) (surgery start time 08:32 AM) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 24's medical record on 4/13/16 at 1:35 PM revealed the patient had a total vaginal hysterectomy on 11/11/15. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 11/11/15 at 12:50 (PM) (surgery start time 12:04 PM) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 25's medical record on 4/14/16 at 1:45 PM revealed the patient had a right laparoscopic inguinal hernia repair on 11/23/15. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 11/23/15 at 12:30 (PM) (surgery start time 12:08 PM) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 26's medical record on 4/14/16 at 2:00 PM revealed the patient had dental extractions on 12/30/15. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 12/30/15 at 08:34 (AM) (surgery start time 08:07 AM) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 27's medical record on 4/14/16 at 2:20 PM revealed the patient had a right laparoscopic inguinal hernia repair on 1/18/16. Review of the Physician Orders Pre-Surgical Exam revealed the physician signature dated 1/18/16 at 09:20 (AM) (surgery start time 08:28 AM) lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 10's medical record on 4/14/16 at 2:10 PM revealed the patient had a right knee arthroscopy on 4/11/16. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
B. Interview with the Vice President of Patient Services on 4/15/16 at 11:00 AM confirmed the above records lacked the physician documented examinations immediately before surgery to evaluate the risks of the procedure to be performed and stated "room for improvement".