HospitalInspections.org

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 5 of 5 discharged surgical patients (Patients 16, 17, 18, 19 and 20). This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 1/1/18 to 7/1/18 was 242.

Findings are:

A. Review of Patient 16's medical record (8/1/18 at 10:35 AM) revealed the patient had dental restoration. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (1:01 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 17's medical record (8/1/18 at 11:05 AM) revealed the patient had laparoscopic cholecystectomy (specialized technique to remove the gallbladder that avoids the long incision used in open surgery). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (2:16 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 18's medical record (8/1/18 at 11:15 AM) revealed the patient had extracorporeal shock wave lithotripsy (non-invasive treatment of kidney stones using an acoustic pulse). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (8:41 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 19's medical record (8/1/18 at 11:30 AM) revealed the patient had right carpal tunnel release (surgery to treat carpal tunnel syndrome that is pain and weakness in the hand that is caused by pressure on the median nerve in the wrist). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (4:21 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 20's medical record (8/1/18 at 11:45 AM) revealed the patient had the removal of fixation plate and screws, right ankle. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (12:54 PM) to evaluate the risk of the procedure to be performed.

B. Interview with the Director of Nursing (8/2/18 at 8:10 AM) confirmed the above medical records lack the evidence of the patient examinations completed by the physicians immediately before surgery to evaluate the risk of the procedure to be performed stating "We know its not in there".