HospitalInspections.org

Based on medical record (MR) review, interview, and document review, an ambulatory surgical patient (Patient #2) required an unplanned overnight hospital stay due to not meeting discharge criteria. The operating surgeon was not aware that Patient #2 did not meet discharge criteria and was staying overnight; therefore no physician orders were written. Additionally, the MR lacked documentation that nursing staff monitored the patient overnight.

Findings include:

-- Per MR review, on 10/30/2024, Patient #2 presented to the ambulatory surgical unit (ASU) for a scheduled same-day surgery. Following surgery, Patient #2 experienced low oxygen saturations and did not meet discharge criteria. Patient #2 was transferred from the ASU to a medical surgical floor at 8:22 pm to spend the night for further monitoring and observation. The MR lacked a physician order for Patient #2's inpatient stay and orders for medical care. The MR also lacked documentation of monitoring of Patient #2's oxygen saturation and oxygen use from 12:44 am to 8:40 am (on 10/31/2024). On 10/31/2024 at 8:41 am, physician orders were written for Patient #2's inpatient stay and medical care.

-- Per interview of Staff A, Registered Nurse (RN) on 1/28/2025 at 12:05 pm, they called the Post-Anesthesia Care Unit asking to speak with the surgeon for Patient #2 as they were experiencing low oxygen saturations and not meeting discharge criteria. Staff A was told that the surgeon was busy, in surgery, and could not come to the phone. Staff A then notified the nursing supervisor of not being able to speak directly with the surgeon. The nursing supervisor instructed Staff A to transfer Patient #2 to the floor for inpatient admission. Staff A transferred Patient #2 to the floor as instructed by the nursing supervisor.

-- Per interview of Staff B, Nursing Supervisor on 1/28/2025 at 10:25 am, they confirmed that they were contacted by Staff A and directed them to transfer Patient #2 to the medical surgical floor for inpatient admission. Staff B stated the surgeon should have been contacted, and this was a "hiccup" in the process. Staff B stated they called the surgeon the following morning as soon as the lack of notification was identified.

-- Per interview of Staff C, Surgeon on 1/28/2025 at 9:00 am, they indicated they were never contacted and made aware that Patient #2 had not met discharge criteria and needed to spend the night. Staff C confirmed that they were notified the following morning and issued orders at that time.

-- Review of the facility's policy and procedure titled "Transfer or Admission to Acute Care," (revised 8/2024) indicated the ASU RN "must be informed by the operating practitioner and/or anesthesiologist of the need for the patient's admission as an inpatient or observation status. ... A physician order indicating said change will be issued to Patient Registration in order to process the requested change. ... Orders will be obtained from the operating practitioner."

-- Review of the facility's policy and procedure titled "Nursing Assessment," (revised 2/2023) indicated " ... assessment will allow for ongoing monitoring during hospitalization as well as identify changes that may indicate a change in the patient's condition. ... A focused re-assessment specific to patient condition will be conducted as needed/indicated per nursing judgment, protocol, or physician order."

-- During interview of Staff D, Chief Quality Officer on 1/28/2025 at 9:45 am and Staff B on 1/28/2025 at 10:25 am, they confirmed the above findings.