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Based on interviews and facility and patient medical record review, the facility failed to ensure the patient's right to make informed decision by having the patient or the patient's representative sign their anesthesia consent prior to being informed of the risks and benefits by anesthesia for 3 of 30 patient medical records reviewed (#21, #22 and #29).

The findings include:

1. On February 8, 2012 at approximately 08:45am an interview was conducted with the Pre-op LPN in the presence of the Charge Nurse and Risk Manager. The pre-op nurse stated that during the patient's preoperative visit the patient signs their anesthesia consent. She stated that the anesthesia consent is signed before the patient sees the anesthesiologist.

2. On February 8, 2012 at 09:15am an interview as conducted with the Anesthesiologist. She stated that sometimes they see the patient at the time of the preop appointment, not always. She admitted that anesthesia consent are usually signed before Anesthesia has spoken with the patient, but that anesthesia does inform the patient and that pre-op anesthesia assessments are performed on all patients prior to surgery. The Anesthesiologist agreed that this was not informed consent.

3. The facility's policy entitled Informed Consents indicates B......1. Physician: It is the physician's duty to inform the patient prior to obtaining consent to any medical treatment or procedure. In order for a patient's consent to be considered "informed", the physician must advise the patient of his condition, the proposed treatment, any available forms of alternative treatment, the risk and possible consequences of the proposed treatment plan, and the chances of failure".

4. On 02/09/2012 during a medical record review for patient #21, the anesthesia consent was signed by the patient on 09/27/2011 at 09:45. The anesthesia provider, signed and dated the consent on 09/27/11 at 15:45. The patient was not explained the risk and benefits of anesthesia before signing his consent.

During a medical record review for patient #22, the anesthesia consent was signed by the patient's guardian on 01/31/2012 at 1440. The anesthesia providers signed the consent on 02/01/2012 at 09:25. The patient/patient's guardian was not explained the risk and benefits of anesthesia before signing of the consent.


During a medical record review for patient #29, the anesthesia consent was signed by the patient on 02/02/12 at 08:55. The anesthesia provider, signed and dated the consent on 02/02/12 at 09:35. The patient was not explained the risk and benefits of anesthesia before signing his consent.

Based on observation and interview, the facility failed to document provision of Healthcare Advance Directives for 5 of 30 adult patients reviewed. ( # 8, 9, 26, 27, and 28).

Findings include:

1) Review of thirty medical records, both open and closed, revealed that the section of the record related to advance directives was not completed on patients #8, #9, #26, #27, and #28. This section of the records pertains to whether the patient does or does not have a current advance directive, and, if not, whether they are interested in obtaining from the facility, information regarding advance directives.

2) On 2/9/12 at approximately 12:30 pm, an interview with the Chief Nursing Officer was conducted. He was asked, based on the documentation in the record, if the advanced directive status of the patients chosen for record review, had been addressed. He stated that it had not, and that he was already aware that the staff was not consistently addressing the issue with the patients, on admission. He added that he had actually had an in-service with the staff this week regarding the information not being on the records.

Based on interview and patient record review, the facility failed to ensure that physician orders were signed by the physician for 1 of 30 sampled patient medical records reviewed (#30).

The findings include:

1. On February 9, 2012 during a medical record review conducted for patient #30, admit date 2/6/2012. The physician failed to sign the Pre-Printed Admitting Orders.

2. On February 9, 2012 during an interview with the Chief Nursing Officer at approximately 1:30pm, he stated the order should have been signed by the physician immediately.

Based on observation, interview and facility policy review the facility failed to ensure that medications in the facility's crash carts were not outdated.

The findings include:

1. On February 7, 2012, at 09:50am a tour of the Emergency Room Department was conducted, accompanied by the Risk Manager and then later joined by the Chief Nursing Officer (CNO). The Emergency room crash carts were inspected. Medications noted to be expired were:
Pediatric Crash Cart:
(3) 2% Lidocaine HCL injectable glass Abbojects in box, expired 1 February 2012
Adult Crash Cart (trauma rooms):
(1) 2% Lidocaine HCL injectable glass Abboject in box, expired 1 February 2012
(1) 2% Lidocaine HCL injectable glass Abboject in box, expired 1 January 2012
(1) Epinephrine 1:1000 (30ml) multidose vial, expired December 2011
(5) Vasopressin 20 units/ml single dose vial, expired January 2012
(5) Verapamil HCL 5mg/ml 2ml single dose vial, expired 1 January 2012
Adult Crash Cart (room 11)
(5) Verapamil HCL 5mg/ml 2ml single dose vial, expired 1 January 2012

The expired medications were confirmed with the Risk Manager and the Chief Nursing Officer. The CNO stated that the crash cart contents are checked once a month and noted on logs sheets.

A review of the Emergency Room crash cart log - failed to indicate that the Crash Cart contents for medication had been check the month of January.

On February 8, 2012 at 09:00am a tour of the Surgical Department was conducted, accompanied by the Charge Nurse for Surgical services, the contents of the crash cart were inspected. Medications noted to be expired were:
(1) 2% Lidocaine HCL injectable glass Abboject in box, expired 1 February 2012
(2) 2% Lidocaine HCL injectable glass Abboject in box, expired 1 January 2012
(2) Magnesium Sulfate - multidose vial, expired January 2012
(6) 0.9% Na Chloride injection, expired 1/1/2012
(2) 0.9% Na Chloride single dose vials, expired 1 December 2011

The expired medications were confirmed with the Charge Nurse. He stated that he was the one responsible for checking the crash cart contents each month and he just missed it.

On February 8, 2012 at 10:50am a tour of the Radiology Department was conducted, accompanied by the Radiology Director, the contents of the crash cart were inspected. Medications noted to be expired were:
(2) 2% Lidocaine HCL injectable glass Abboject in box, expired 1 February 2012
(1) Nitropress 50mg/2ml., expired 07/01/2011

The facility's policy entitled Emergency Carts/Defibrillators Checks reads under "General Information: ...."6. All carts will be opened and checked for contents once monthly and following each use. Sterile items will be check for package integrity and expiration date. Items with expiration dates expiring within the month will be replaced."

Based on interviews and patient record review, the facility failed to ensure the provision of an immediate pre-anesthesia evaluation was performed on the patient immediately prior to surgery and failed to ensure that physician orders were dated appropriately for 5 of 30 patient records reviewed (#21, #22, #25, #26, #29)

The findings include:

On February 9, 2012 during a medical record review for patient #21, the anesthesia provider signed and dated the pre-op anesthesia assessment on 09/27/2011 at 1540. The patient had surgery on 09/28/2011. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #22, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/01/2012 at 0920. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery. The physician orders were faxed to the hospital on 01/19/2012, the date on the ENT order sheet was signed by the physician on 10 Jun 2010. The patient had surgery on 02/07/2012.

During a medical record review for patient #25, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/03/2012 at 0900. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #26, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 01/26/2012 at 13:50. The patient had surgery on 02/06/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #28, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/02/2012 at 0930. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

2. On February 9, 2012 at approximately 1:30pm, the Chief Nursing Officer, Risk Manager and Nursing Manager all confirmed the lack of provision to indicate that a pre-anesthesia assessment was conducted immediately prior to surgery for all 5 records.

1. On February 8, 2012 at approximately 08:45am an interview was conducted with the Pre-op LPN in the presence of the Charge Nurse and Risk Manager. The pre-op nurse stated that during the patient's preoperative visit the patient signs their anesthesia consent. She stated that the anesthesia consent is signed before the patient sees the anesthesiologist.

2. On February 8, 2012 at 09:15am an interview as conducted with the Anesthesiologist. She stated that sometimes they see the patient at the time of the preop appointment, not always. She admitted that anesthesia consent are usually signed before Anesthesia has spoken with the patient, but that anesthesia does inform the patient and that pre-op anesthesia assessments are performed on all patients prior to surgery. The Anesthesiologist agreed that this was not informed consent.

3. The facility's policy entitled Informed Consents indicates B......1. Physician: It is the physician's duty to inform the patient prior to obtaining consent to any medical treatment or procedure. In order for a patient's consent to be considered "informed", the physician must advise the patient of his condition, the proposed treatment, any available forms of alternative treatment, the risk and possible consequences of the proposed treatment plan, and the chances of failure".

4. On 02/09/2012 during a medical record review for patient #21, the anesthesia consent was signed by the patient on 09/27/2011 at 09:45. The anesthesia provider, signed and dated the consent on 09/27/11 at 15:45. The patient was not explained the risk and benefits of anesthesia before signing his consent.

During a medical record review for patient #22, the patients informed consent for surgery was signed on 01/03/2012. The patient's surgery was performed on 02/07/2012, more than 30 days from the date the consent was signed. Consents are valid for 30 days. The patients anesthesia consent was signed on 01/31/2012 at 1440. The anesthesia providers signed the consent on 02/01/2012 at 09:25. The patient/patient's guardian was not explained the risk and benefits of anesthesia before signing of the consent.

During a medical record review for patient #24, the anesthesia consent was not dated or timed by the patient as to when the consent was signed.

During a medical record review for patient #29, the anesthesia consent was signed by the patient on 02/02/12 at 08:55. The anesthesia provider, signed and dated the consent on 02/02/12 at 09:35. The patient was not explained the risk and benefits of anesthesia before signing his consent.

During a medical record review for patient #30, the patient's informed consent failed to be signed by the operating physician. Per the Chief Nursing Officer, is is the policy of the hospital that the physician should sign the consent.


Anesthesia failed to inform the patient prior to obtaining consent, consent was signed greater than 30 days and consent was not signed by operating physician.

Based on interviews and patient record review, the facility failed to ensure the provision of a pre-anesthesia evaluation was performed on the patient within 48 hours prior to surgery for 4 of 30 patient records reviewed. (#22, #25, #26, #29)

The findings include:

During a medical record review for patient #22, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/01/2012 at 0920. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #25, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/03/2012 at 0900. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #26, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 01/26/2012 at 13:50. The patient had surgery on 02/06/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

During a medical record review for patient #28, the anesthesia provider signed and dated that the pre-op anesthesia assessment was completed on 02/02/2012 at 0930. The patient had surgery on 02/07/2012. The record failed to show the provision of a pre-anesthesia assessment being performed immediately before surgery.

2. On February 9, 2012 at approximately 1:30pm, the Chief Nursing Officer, Risk Manager and Nursing Manager all confirmed the lack of provision to indicate that a pre-anesthesia assessment was conducted immediately prior to surgery for all 4 records.