HospitalInspections.org

26711

Based on Medical Record (MR) review, staff interview, and review of policy and procedure and documentation related to the correction of this citation, this facility failed to ensure proper evaluations for anesthesia recovery were completed in 5 of 5 Patients (Pt.'s #6, 7, 8, 9, and 10) closed surgical MRs out of a total of 15 MR reviewed.

Findings include:

A review of the packet submitted as data gathered for the correction of this citation was done on 3/13/2012 at 8:00 a.m. The packet contained two e-mails from the previous Quality Coordinator (QC D), one dated 11/29/2011 and one with a hand written date of 12/19 on it. The e-mails cover detailed information between QC D and the Anesthesia department regarding changes to be instituted to the facility's post-anesthesia evaluation documentation.

The packet also contains a policy titled, "Responsibilities-Nurse Anesthesia," with a review date of 10/11. This policy has been updated to reflect the changes to be made to the post-anesthesia evaluation.

The packet also contains a form titled, "Post Anesthesia Evaluation," which has a revision date of 8/31/11 in the bottom left corner and the facility's logo in the upper left corner. This form has not been instituted for use in the facility yet.

In an interview with Registered Nurse (RN) C on 3/13/2012 at 9:15 a.m., RN C confirmed that the anesthesia department had not started using the form yet. When Surveyor #26711 inquired as to why this had not occurred yet RN C replied, "We have been fighting with the print shop."'

MR reviews for Pt.'s #6, 7, 8, 9, and 10 were completed on 3/13/2012 between 8:45 a.m. and 10:07 a.m. in the presence of QC B who was available for questions and validation of findings during the MR reviews.

Pt. #10 had surgery on 1/16/2012 with general anesthesia . Anesthesia started at 7:55 a.m. and ended at 9:30 a.m. Pt. #10 was taken to the Post Anesthesia Care Unit (PACU) at 9:30 a.m. At 9:26 a.m. Pt. #10 was extubated (tube for breathing during surgery was removed from the throat), however there is no time recorded for when the post-anesthesia evaluation (eval) occurred.

Pt. #9 had surgery on 1/17/2012 with general anesthesia. Anesthesia started at 12:25 p.m. and ended at 2:10 p.m. Pt. #9 was taken to PACU at 2:05 p.m. The post-anesthesia eval is documented at 2:05 p.m.

Pt. #8 had surgery on 1/23/2012 with general anesthesia. Anesthesia started at 9:50 a.m. and ended at 12:20 p.m. Pt. #8 was taken to PACU at 12:15 p.m. There is no time documented for the post-anesthesia eval.

Pt. #6 had surgery on 2/7/2012 with general anesthesia. Anesthesia started at 7:55 a.m. and ended at 9:55 a.m. Pt. #6 was taken to PACU at 10:00 a.m. The post-anesthesia eval is documented at 10:00 a.m.

Pt. #7 had surgery on 2/24/2012 with general anesthesia. Anesthesia started at 11:55 a.m. and ended at 1:40 p.m. It is documented that Pt. #7 was taken to PACU at 11:45 a.m., however RN C and QC B reviewed this documentation with Surveyor #26711 at 9:00 a.m. and it was determined that this time was incorrectly documented and the time should have been 1:40 p.m. The post-anesthesia eval is documented at 1:45 p.m.

These findings were again discussed at exit on 3/13/2012 at 11:35 a.m. with Chief Executive Officer E, Chief Nursing Officer A, QC B, and RN C who are all in agreement that the documented times did not allow for an adequate amount of time to elapse to perform a post-anesthesia evaluation to determine if the patient has adequately recovered from the anesthesia.