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Based on document review and interview, it was determined that the Hospital failed to ensure that anesthesia services were responsible for all anesthesia services provided, by not ensuring the anesthesiologist provided safe and continuous care to a patient under general anesthesia. As a result, the Condition, 42 CFR 482.52, Anesthesia Services, was not met.


Findings include:

1. The Hospital failed to ensure that the anesthesiologist remained in the operating room for continuous monitoring of a patient who was under general anesthesia. A-1002

The immediate jeopardy began on 11/30/2021, due to the Hospital's failure to ensure that the anesthesia services were consistent with the needs and resources of the Hospital, by not ensuring the anesthesiologist provided safe and continuous care to a patient under general anesthesia; and was identified on 12/8/2021 at 42 CFR 482.52, Anesthesia Services. The IJ was announced on 12/8/2021 at 9:16 AM during a meeting with the Vice President of Nursing, Chief Operating Officer, and the Patient Safety Officer and was removed by the survey exit date of 12/9/2021.
The condition, 42 CFR 482.52, Anesthesia Services, remains out of compliance due to inability to ensure/verify sustained compliance.

Based on document review and interview, it was determined that for 1 of 1 Anesthesiologist (MD #1) providing general anesthesia during a surgical procedure on 11/30/2021, the Hospital failed to ensure that the anesthesia services were consistent with the needs and resources of the Hospital by not ensuring the anesthesiologist provided safe and continuous care to a patient under general anesthesia. This failure is likely to cause serious harm, injury or death to patients undergoing general anesthesia.

Findings include:

1. On 12/6/2021, the policy titled, "Standards for Basic Intraoperative Monitoring" dated 7/18/2021, was reviewed. The policy included, " ...2. Objective: Because of the rapid change in patients status during anesthesia, qualified anesthesia personnel shall be continuously present to monitor the patients and provide anesthesia care ..."

2. On 12/7/2021, the incident report, dated 12/1/2021, with an event date of 11/30/2021, was reviewed. The report included, "It was reported that [MD #1] who was the Anesthesia provider for a dental case in Rm #6, left the room while the patient was intubated (for 20-30 minutes) and went to ODS [One day surgery] to give another patient a IM [intramuscular] injection ..."

3. On 12/7/2021, Pt. #12's surgery clinical record, dated 11/30/2021, was reviewed. Pt. #12 was under general anesthesia, provided by the anesthesiologist (MD #1), from 8:11 AM - 10:25 AM, for a complete oral rehabilitation. Based on the anesthesia intraoperative report, the length of time that MD #1 was out of the OR durimg Pt #12's surgery could not be determined.

4. On 12/7/2021, Pt. #13's surgery clinical record, dated 11/30/2021, was reviewed. Pt. #13's pre-operative nursing showed that Pt. #13 was admitted to the one day surgery unit on 11/30/2021 at 9:04 AM. The medication summary for Pt. #13 showed that MD #1 removed versed (sedative) for Pt. #13 from the medication cart on 11/30/2021 at 9:12 AM, but the administration time of the versed by MD #1 was not documented.

5. On 12/6/2021 at 11:26 AM, an interview was conducted with an Anesthesiologist (MD #2). MD #2 stated that when a patient receives anesthesia, the Anesthesiologist or Certified Registered Nurse Anesthetist must remain with the patient throughout the surgical procedure.

6. On 12/7/2021 at approximately 11:33 AM, an interview was conducted with MD #1 (Anesthesiologist). MD #1 stated that she left Pt. #12 (4 year old), who was under general anesthesia, in the OR, while the Post Anesthesia Care Unit RN monitored Pt. #12's status during surgery. MD #1 stated that Pt. #13 was in the one day surgery holding area exhibiting behaviors and needed sedation to calm down. MD #1 stated that she left the OR (3rd floor) and went to one day surgery (4th floor) to administer versed (sedative) to Pt. #13. MD #1 stated that Pt. #12 was stable, and she (MD #1) was out of the OR no longer than 5-7 minutes.

7. On 12/7/2021, at approximately 12:00 PM, an interview was conducted with the PACU (post anesthesia care unit) RN (Registered Nurse) (E #6). E #6 stated that MD #1 came and got her out of the PACU (there were no patients in the PACU at that time) and told her to come with her. E#6 stated that MD #1 led her to the dental operating room (OR #6) and told her to monitor the patient (Pt #12) because there was an emergency, and MD #1 needed to go up to one day surgery to administer an IM (intramuscular) injection to another patient (Pt #13). E #6 stated that about 7 minutes passed, and MD #1 had not yet returned. E #6 stated that she was very uncomfortable and called MD#1 and told her she needed to return to OR #6 to monitor Pt #12. E #6 stated that this incident happened on 11/30/2021 around 9:15 AM. E #6 stated that the nurses that were with Pt #13 could have administered the IM injection, and it is within the scope of what they are able to do.

8. On 12/6/2021 at 11:26 AM, an interview was conducted with an Anesthesiologist (MD #2). MD #2 stated that the anesthesiologist or CRNA are required to remain in the operating room once a patient is administered anesthesia.

9. On 12/7/2021 at 12:54 PM, an interview with the Patient safety Officer (E #7) was conducted. E #7 stated that there has not been any corrective action implemented regarding the incident with MD #1. E #7 stated that he plans to interview MD #1 today (12/7/2021) and possibly do a root cause analysis.

Based on document review and interview, it was determined that for 1 of 13 (Pt. #12) surgery clinical records reviewed for anesthesia records, the Hospital failed to ensure that the intraoperative anesthesia record was complete with the patient's vital signs, electrocardiogram (EKG) interpretation, and oxygen levels for the entirety of a surgical procedure.

Findings include:

1. On 12/06/2021, "Standards for Basic Intraoperative Monitoring" reviewed by the Hospital 7/18/2021, was reviewed. The policy included, "...3. Standard II: During all anesthetics, the patient's oxygenation, ventilation, circulation and temperature shall be continually monitored and evaluated...11. Methods...b. All above monitoring shall be documented in the anesthesia record and any changes or variations so documented."

2. On 12/7/2021, Pt. #12's surgery clinical record, dated 11/30/2021, was reviewed. Pt. #12 was under general anesthesia from 8:11 AM - 10:25 AM, for a complete oral rehabilitation. The intraoperative anesthesia record lacked documentation of temperature, EKG interpretation, and oxygen levels from 9:00 AM - 10:27 AM (end of surgery).

3. On 12/6/2021 at 11:26 AM, an interview was conducted with an Anesthesiologist (MD #2). MD #2 stated that patient vitals signs should be monitored and documented on the anesthesia record every 5 minutes.