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A review of medical records (MR) and interviews with staff (EMP) it was determined the facility failed to ensure the patient's right to have the primary care provider notified upon admission to the hospital for seven of 22 medical records reviewed (MR1, MR3, MR5, MR6, MR7, MR8, and MR9).

Findings include.

Review on September 28, 2016, of MR1, MR3, MR5, MR6, MR7, MR8, and MR9 revealed that these patients were admitted to the hospital. There was no documented evidence patients were asked if they wanted their primary care provider notified of their admission to the hospital and/or that their primary care physician was notified by the facility of the patient's admission to the hospital.

An interview conducted on September 28, 2016, at 10:15 AM, with EMP10 confirmed there was no documented evidence in the medical records asking patients whether they wanted their primary care physician notified of their admission.

An interview conducted on September 29, 2016, at 10:00 with EMP11 revealed the facility did not have a policy that addressed notification of the Primary Care Physician upon admission to the hospital.

A review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that staff failed to follow the facility policy for assessment of patients pain levels after pain medication administration for six of 22 medical records (MR4, MR14, MR15, MR17, MR18, and MR19) reviewed.

Findings include:

Review of facility policy entitled "Pain Management" last reviewed February 1, 2016, revealed, " ... C. Screen and treat patients for pain ... during ongoing, and periodic reassessments. ... Demonstration/Documentation-healthcare workers document: Demonstration of ongoing and comprehensive pain assessment ... Systematic evaluation of treatment effectiveness ..."

1) A review of MR4 on September 28, 2016, revealed the patient received pain medication on July 7, 2016, at 9:55 AM and 12:30 PM. There was no documentation of reassessment of pain levels.

2) A review of MR14 on September 29, 2016, revealed the patient received pain medication on the following dates and times: June 22, 2016, at 1435, 2000, 2030, and 0645. There was no documentation of reassessment of pain levels.

3) A review of MR15 on September 29, 2016, revealed the patient received pain medication on the following dates times: June 2, 2016, at 1648, and 2217. There was no documentation of reassessment of pain levels.

4) A review of MR 17 on September 29, 2016, revealed the patient received pain medication on April 28, 2016, at 0815, and 1925: April 29, 2016, at 0600, and 1700. There was no documentation of reassessment of pain levels.

5) A review of MR18 on September 29, 2016, revealed the patient received pain medication on the following dates and times: June 16, 2016, at 2015 and 2345; June 17, 2016, at 0620, 1045, 1200, and 2000; June 18, 2016, at 0045, 0340, 0618, 1030 and 1715. There was no documentation of reassessment of pain levels.

6) A review of MR19 on September 29, 2016, revealed the patient received pain medication on the following dates and times: May 18, 2016, at 1950; May 19, 2016, at 0010, 0515, 0845, 1305, 1620 and 1950; May 20, 2016, at 0005 and 0445. There was no documentation of reassessment of pain levels.

Interview with EMP 9 confirmed on September 29, 2016, that MR4, MR18 and MR19 had received pain medications and the response to the pain medication had not been documented.

A review of facility documents, medical records (MR) and interview with staff (EMP) it was determined the Director of Anesthesia failed to ensure that Anesthesia policy was followed for obstetric patients who had Cesarean Section and received epidural anesthesia who were to have been evaluated post operatively for five of seven records (MR4, MR18, MR19, MR20 and MR21) reviewed.

Findings include:

A review of St. Joseph Regional Health Network Anesthesia Services Policies and Procedures entitled "Post Anesthesia Evaluation" last reviewed April 1, 2016, revealed, " ... A post-anesthesia evaluation: ... Should be performed on postoperative day # 1 for patients admitted to ... OB ... and documented in the progress note. ... Checklist (for last 24 hours ) will be given to on-call CRNA and Anesthesiologist who will be responsible to make sure that all patients have completed evaluation. ... "

1) A review on September 28, 2016, of MR4 revealed the obstetric patient had epidural anesthesia ordered on July 5, 2016. There was no post-operative anesthesia evaluation documented in the record. MR4 complained of headache and received pain medication on July 7, 2016, and was discharged to home. MR4 presented to the Emergency Department on July 9, 2016, for complaints of headache. MR4 was diagnosed with Spinal Headache and treated with "blood patch."

2) A review on September 29, 2016, of MR18 revealed the obstetric patient had epidural anesthesia ordered on June 6, 2016. There was no post-operative anesthesia evaluation documented in the record.

3) A review on September 29, 2016, of MR19 revealed the obstetric patient had epidural anesthesia ordered on May 17, 2016. There was no post-operative anesthesia evaluation documented in the record.

4) A review on September 29, 2016, of MR20 revealed the obstetric patient had epidural anesthesia ordered on June 1, 2016. There was no post-operative anesthesia evaluation documented in the record.

5) A review on September 29, 2016, of MR21 revealed the obstetric patient had epidural anesthesia ordered on April 15, 2016. There was no post-operative anesthesia evaluation documented in the record.

An interview conducted with EMP 8 on September 28, 2016, at 1:40 PM confirmed that MR4 had no anesthesia follow up documented. Further interview confirmed that Cesarean Section patients who received an epidural were to be followed the next day and the evaluation documented in the progress notes.

An interview conducted with EMP 8 on September 29, 2016, at 11:30 AM confirmed MR18, MR19, MR20 and MR21 had no follow up evaluation by anesthesia documented in the medical records.