HospitalInspections.org

Based on review of medical records, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to ensure each surgical patient had a complete history and physical examination documented for 2 of 6 surgical medical records (Records 16 and 21) reviewed. Patient census on first day of survey was 5 (4 acute inpatients and 1 swing bed patient).

Findings are:

A. Review of Medical Record 16 on 8/14/13 at 1:40 PM revealed the patient had bilateral myringotomy with placement of ventilation tubes (ear incision with tube placement) done on 5/7/13. The medical record revealed ENT (Ear, Nose [and] Throat) Clinic note which included chief complaint/history of present illness, past medical history and treatment plan for surgery. Review of the entire medical record revealed a lack of evidence of a physical exam including the review of systems.

Review of Medical Record 21 on 8/14/13 at 2:25 PM revealed the patient had a tonsillectomy and adenoidectomy done on 2/12/13. The medical record revealed a SOP (Subjective, Objective, Plan) note which included chief complaint/history of present illness, past medical history and treatment plan for surgery dated 1/29/13. Review of the entire medical record revealed a lack of evidence of a physical exam including the review of systems.

B. Review of policy and procedure titled Medical Record Content (revised 4/07) stated History and Physical Examination include "Review of the systems, including a minimum review of the cardiovascular, respiratory, genitourinary and gastrointestinal systems".

C. Interview with the Director of Health Information Management and the Operating Room Manager on 8/14/13 at 4:30 PM confirmed the lack of physical exams that included the review of systems in the above medical records.

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure a physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed for 6 of 6 surgical medical records (Records 16, 17, 18, 19, 20 and 21) reviewed. Patient census on first day of survey was 5 (4 acute inpatients and 1 swing bed patient).

Findings are:

A. Review of Medical Record 16 on 8/14/13 at 1:40 PM revealed the patient had bilateral myringotomy with placement of ventilation tubes (ear incision with tube placement) done on 5/7/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

Review of Medical Record 17 on 8/14/13 at 1:55 PM revealed the patient had mesh repair of right inguinal hernia done on 5/14/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

Review of Medical Record 18 on 8/14/13 at 2:10 PM revealed the patient had reduction and mesh repair of umbilical hernia done on 4/23/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

Review of Medical Record 19 on 8/14/13 at 2:15 PM revealed the patient had reduction and mesh repair of left scrotal hernia done on 3/5/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

Review of Medical Record 20 on 8/14/13 at 2:20 PM revealed the patient had laparoscopic tubal ligation done on 3/19/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

Review of Medical Record 21 on 8/14/13 at 2:25 PM revealed the patient had a tonsillectomy and adenoidectomy done on 2/12/13. Review of the entire medical record revealed the record lacked evidence of a physician exam immediately before surgery to evaluate the risk of the procedure to be performed.

B. Interview with the OR (Operating Room) Manager and the Director of Health Information Management on 8/14/13 at 4:45 PM confirmed the above medical records lacked the physician documented examinations immediately before surgery that evaluate the risk of the procedure to be performed. The OR Manager stated "If it has to be done day of [surgery], it's not being done by the doctors."