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Based on observation, interview, and record review, the facility failed to ensure that the medical history and physical examination (H & P) be completed no more than 30 days, prior to scheduled procedures, for 3 of 3 sampled patients. (Patients 141, 142, and 143) This failure may result in inaccurate documentation of patients conditions and status, prior to a procedure.

Findings:

On 4/22/13 at 9:40 am, Patient 142 was observed lying supine on a table in the center of the Cardiac Cath Suite. A heart monitor was on the patient monitoring his heart rhythm and rate, blood pressure, and oxygen saturation level (assessment tool for oxygen level in blood). A sterile prep (disinfection of entry site) to the expected entry sites was observed being performed by Nurse Manager (NM) 18, then sterile drapes were placed around the entry sites. The surgical checklist (a list of required documentation and third review by nursing) was signed off as completed by Registered Nurse (RN) 68. The record contained a H & P, dated 3/22/13 (31 days) and no interval update. When the 31 day H & P was brought to RN 68's attention, she stated that she had calculated the date from 3/23/13, when Medical Staff Member (MSM) 61 signed off the H & P and confirmed the H & P occurred on 3/22/13.

On 4/22/13 at 10:05 am, MSM 61 entered the Cardiac Cath Suite. MSM 61 was informed he needed to do another H & P, since the current one was over 30 days. MSM 61 was observed reviewing Patient 142's record. MSM 61 did not speak to the patient. The "Time Out" procedure to confirm the correct patient, procedure, and pertinent information was discussed with the team members at 10:13 am.

A review of the record after the procedure provided documentation that MSM 61 conducted a H & P at 10:10 am (while Patient 142 was in Cardiac Cath Suite prepped for the procedure) and an interval update to the H & P was documented at the same time. A Mallampati Scale (a visual clinical instrument used to assess the ease of obtaining an airway by direct observation), was documented as Class II by MSM 61 at 10:10 am. From the time when MSM 61 entered the procedure room to the beginning of the procedure, there was no physical exam conducted by MSM 61 for Patient 142, as required by facility policy and nationally recognized standards of practice.

On 4/22/13, three procedures were scheduled in Cardiac Cath Lab for Medical Staff Member (MSM) 61:
Patient 141 had a H & P conducted on 1/30/13, 82 days prior to procedure.
Patient 142 had a H & P conducted on 3/22/13, 31 days prior to procedure.
Patient 143 had a H & P conducted on 2/15/13, 66 days prior to procedure.

In an interview on 4/22/13 at 2:10 am, MSM 61 stated that it was "very rare" to have a H & P occur greater than 30 days, prior to the scheduled procedures in Cardiac Cath Lab. He stated that he conducted the H & P while Patient 142 was lying under sterile drapes on the table. MSM 61 stated that he did the best he could, but was limited in conducting the physical exam due to the position of the patient and sterile drapes prevented him from doing a complete history and physical. He stated he did not talk to the patient, but was able to get the necessary information from his record. During the interview, MSM 61 was notified via telephone that he had to conduct another H & P.

According to the facility's Medical Staff Rules and Regulations, dated 8/12, "A-3 A medical history and physical examination is to be completed no more than 30 days, prior to or within 24 hours after inpatient admission. For a medical history and physical examination that was completed within 30 days prior to inpatient admission, an update documenting any changes in the patient's condition is completed within 24 hours after inpatient admission or prior to surgery...A - 4 A history and physical is required for all patients with the exception of outpatients presenting for treatment or procedures covered by the Conditions of Admission form which do not require a separate consent. The history and physical must contain: 1) history of present illness; 2) medical and surgical history, medications, and allergies; 3) physical exam; 4) impression; 5) plan. Chief complaint, review of systems, family history, and social history should be included when pertinent but not necessarily under separate headings."

Based on observation, interview, and record review, the facility failed to ensure that an updated examination of the patient was conducted when the History and Physical (H & P) was completed within 30 days, before the procedure for 10 of 10 Medical Staff Members (MSM 61, 62, 63, 64, 65, 66, 67, 68, 69, and 70). This failure may result in not identifying potential problems that could result in complications.

Findings:

On 4/22/13 at 9:40 am, Patient 142 was observed lying supine on a table in the center of the Cardiac Cath Suite. A heart monitor was on the patient monitoring his heart rhythm and rate, blood pressure, and oxygen saturation level (assessment tool for oxygen level in blood). A sterile prep (disinfection of entry site) to the expected entry sites was observed to be performed by Nurse Manager (NM) 18, then sterile drapes were placed around the entry sites. The surgical checklist (list of required documentation and third review by nursing) was signed off as completed by Registered Nurse (RN) 68. The record contained a H & P, dated 3/22/13, (31 days) and there was no interval update (Refer to A 359).

On 4/22/13 at 10:05 am, MSM 61 entered the Cardiac Cath Suite. MSM 61 was observed reviewing Patient 142's record. MSM 61 did not speak to the patient. The "Time Out" procedure to confirm the correct patient, procedure, and pertinent information was discussed with the team members at 10:13 am.

A review of the record after the procedure provided documentation that MSM 61 conducted an interval update at 10:10 am (while Patient 142 was in Cardiac Cath Suite prepped for the procedure). A Mallampati Scale (a visual clinical instrument used to assess the ease of obtaining an airway by direct observation) was documented as Class II by MSM 61 at 10:10 am. From the time when MSM 61 entered the procedure room to the beginning of the procedure, there was no physical exam conducted by MSM 61 for Patient 142 as required by facility policy and nationally recognized standards of practice.

Two confidential interviews conducted on 4/24 and 4/25/13, confirmed that the normal practice for all Cardiac Cath procedures was that the medical staff members (MSM 61 through 70) always conducted their interval updates while the patients were on the procedure table, draped, and ready for the procedure. Both stated that it would be impossible to conduct an updated examination of the patient while they were positioned on the table for the procedure. In all other procedures, the interval update was conducted in the preoperative area before the patient was taken into the procedure room.

In an interview on 4/25/13 at 9:30 am, MSM 62 stated he thought the "new regulation," interval update assessment prior to patients entering the Cardiac Cath suite, was not practical for the doctors and that other health facilities were not requiring the interval update, prior to patients entering the procedure room. The "new regulation" referred to by MSM 62 had been in effect since 10/17/08.

According to the facility's Medical Staff Rules and Regulations, dated 8/12, "A-3 ...For a medical history and physical examination that was completed within 30 days prior to inpatient admission, an update documenting any changes in the patient's condition is completed within 24 hours after inpatient admission or prior to surgery."

According to "Procedural Anesthesia/Analgesia - Adult-Hospitalwide," dated 9/24/12, "F. Mallampati Scale - a standardized classification tool to predict ease of intubation (breathing tube) based on a visual assessment by the physician of the anatomy of the oral (mouth) cavity."

In an interview on 4/25/13 at 3:45 pm, the Director of Quality Management stated that the expectation would be that the physician would have the patient open their mouth to evaluate Mallampati Scale.

Based on interview and record review, the facility failed to ensure that one of 42 sampled patients had a history and physical (H&P) examination placed in the record within 24 hours of admission. (Patient 112). This failure has the potential for additional risk for patients due to a failure to communicate conditions that would affect the patients' overall condition.

Findings:

On 4/24/13, Patient 112's record was reviewed. Patient 112 was admitted to the facility on 4/2/13 with a diagnosis of pneumonia. Patient 112's record did not contain any evidence of a completed H&P.

On 4/24/13 at 3 pm, the Health Information Manager Director reviewed Patient 112's record, dictation logs, and unfiled records, and acknowledged that a H&P should have been done, but was not.