HospitalInspections.org

Based on review of medical records, review of policy 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 2 of 12 surgical medical records (24 and 27) reviewed. Total sample size 45. Patient census on first day of survey 17 (13 acute inpatients, 3 outpatient surgical patients and 1 medical observation patient). Findings are:

A. Review of Medical Record 24 on 11/7/12 at 2:20 PM revealed that the patient had a left total knee replacement surgical procedure done on 11/5/2012. 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 Medical Record 27 on 11/7/12 at 2:50 PM revealed that the patient had a laparoscopic appendectomy surgical procedure performed on 6/21/12. 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. Review of the facility policy titled Surgical Case Requirements (dated of 11/12), revealed "The surgeon will examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The surgeon shall document this in the patient record."

-Review of the facility policy titled Surgical Case Requirements (dated of 11/10), revealed "No elective surgical patient will be admitted to the Operating Room unless a pre-op visit has been conducted by OR (operating room) personnel. This visit will include a chart review for completeness of lab reports, physician orders, history and physical exam, informed consent as required by Hospital/Medical Staff standards and completion of the pre-op evaluation by a Qualified Practitioner and a personal visit with the patient to assess patient status and patient education."

C. Interview with the Vice President of Nursing on 11/8/12 at 1:50 PM confirmed the lack of documented examinations by physicians immediately before surgery to evaluate the risk of the procedures to be performed in the above medical records.

Based on review of medical records, review of policy 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 2 of 12 surgical medical records (24 and 27) reviewed. Total sample size 45. Patient census on first day of survey 17 (13 acute inpatients, 3 outpatient surgical patients and 1 medical observation patient). Findings are:

A. Review of Medical Record 24 on 11/7/12 at 2:20 PM revealed that the patient had a left total knee replacement surgical procedure done on 11/5/2012. 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 Medical Record 27 on 11/7/12 at 2:50 PM revealed that the patient had a laparoscopic appendectomy surgical procedure performed on 6/21/12. 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. Review of the facility policy titled Surgical Case Requirements (dated of 11/12), revealed "The surgeon will examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The surgeon shall document this in the patient record."

-Review of the facility policy titled Surgical Case Requirements (dated of 11/10), revealed "No elective surgical patient will be admitted to the Operating Room unless a pre-op visit has been conducted by OR (operating room) personnel. This visit will include a chart review for completeness of lab reports, physician orders, history and physical exam, informed consent as required by Hospital/Medical Staff standards and completion of the pre-op evaluation by a Qualified Practitioner and a personal visit with the patient to assess patient status and patient education."

C. Interview with the Vice President of Nursing on 11/8/12 at 1:50 PM confirmed the lack of documented examinations by physicians immediately before surgery to evaluate the risk of the procedures to be performed in the above medical records.