HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interviews, the facility failed to ensure 1 (Patient 5) of 7 sampled patients who received anesthesia had a completed anesthesia consent signed prior to the start of surgery. This failed practice had the potential to effect all surgical patients at the facility. The facility performed 21,341 surgeries in fiscal year 2024.

Findings are:

A. A review of the Informed Consent policy (last revised 9/2023) revealed:
"PROCEDURE FOR OBTAINING ANESTHESIA CONSENT:
-Staff must obtain the signature of the patient or their surrogate decision maker confirming that Informed Consent was obtained prior to the patient being given anesthesia.
-A properly executed consent form must contain the following: Legible full name and signature of patient or surrogate decision maker authorized to consent on the patient's behalf; Legible full name and signature of witness(es) to consent; Date and time consent is obtained; Type (s) of anesthesia services planned or expected to be used for the procedure.; Full name and signature, with date and time, of the anesthesiologist(s) and/or certified nurse anesthetist (s) will provide anesthesia services. It is the responsibility of the anesthesiologist (s) and/or certified nurse anesthetist(s) to review and discuss information, risks, benefits, alternatives, and consequences of the administration of anesthesia with the patient or their surrogate decision maker prior to the administration of anesthesia."

B. Review of Patient 5's surgical medical record revealed that the 42-year-old patient was admitted on 3/13/2025 at 5:36 AM for L5-S1 transforaminal lumbar interbody fusion surgery (a lower back surgery performed to stabilize the spine and reduce pain by fusing the Lumbar Spine (L) 5 and the Sacral Spine vertebrae (S) 1).

-Review of Patient 5's Consent for Anesthesia Service dated 3/13/2025 revealed the plan to use general anesthesia and the anesthesiologist (Doctor-J) signed the form at 7:00 AM on 3/13/2025. The Consent for Anesthesia Service form dated 3/13/2025 lacked the signature of the patient or a surrogate decision maker prior to the administration of anesthesia. The Registered Nurse (RN-A) signed the anesthesia consent form at 10:11 AM.

-Review of a nurses note documented by RN-A at 10:12 AM stated, "RN present in the room while (Doctor-J) spoke with the patient and (significant other) about anesthesia for today's Operation Room (OR) [surgery]. The RN forgot to have patient sign after verbal agreement. The RN called [significant other] at 9:00 AM and the [significant other] stated they would be right back to the hospital. The RN then called [significant other] again at 10:10 AM to get a telephone consent." The surgery started at 8:18 AM and surgical site closed at 10:06 AM due to a medical emergency.

C. An interview with the Director of Surgery (RN-S) on 5/4/2025 at 1:20 PM stated, "Checking the consents for signatures is part of our review before the patients go into surgery during patient hand off [from preoperative room to surgery suite]. The consents are supposed to be reviewed for completeness during the time out prior to starting surgery." RN-S verified that the Anesthesia consent lacked a signature from the patient or a surrogate decision maker prior to anesthesia.