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Tag No.: C0271
Based on staff interview and review of medical records and policies, it was determined the CAH failed to ensure 4 of 5 therapy patients (#20, #29, #30, and #37), whose records were reviewed, contained complete therapy evaluations and plans of care. In addition, the CAH failed to ensure policies defining and governing therapy services had been developed. This resulted in a lack of guidance for therapy staff. Findings include:
1. Patient #30's medical record documented a 35 year old female who was admitted to the CAH on 6/02/12 and was discharged on 6/08/12. She was admitted for a fractured left leg. She had a previous fracture of her right leg on 5/20/12. The left leg was surgically repaired on 6/02/12.
Patient #30's "DISCHARGE SUMMARY," dated 6/12/12, stated "We had physical therapy work with her to teach her transfers. In the process of doing that, a student therapist had her up and had her walking with walking contrary to physician's orders. When corrected, we worked on transfers only..."
Patient #30's "Post-Op Orders," dated 6/02/12 but not timed, stated "Up with Physical Therapy tomorrow."
Patient #30's hand written PT evaluation by Physical Therapist C, dated 6/03/12 at 11:58 AM, was difficult to read. The objective section of the evaluation stated in its entirety, "Boot on R + stood for my care [approximately] 3 minutes then sat then stood for 2 minutes-into bed feet elevated." The evaluation included a plan for therapy which stated "[illegible word, patient 2 times a day] for there [therapeutic] activity as able. [Illegible word] i stand i." No further PT plan of care was documented. The plan did not state if Patient #30 could bear weight or not.
A PT progress note by Physical Therapist C, dated 6/04/12 at 8:00 AM, stated Patient #30 stood at the bedside. A progress note by Physical Therapist D, dated 6/04/12 at 1:20 PM, stated Patient #30 stood in the walker and took 4 steps. Another progress note by Physical Therapist D, dated 6/05/12 at 7:50 AM, stated Patient #30 stood and ambulated "a few steps to [a wheelchair with moderate assistance]. A progress note by Physical Therapist D, dated 6/05/12 at 1:00 PM, stated Patient #30 ambulated 6 feet with a front wheeled walker and was "...putting a little weight on her [left] leg."
Patient #30's record contained a physician order, dated 6/05/12 at 7:40 PM, which called for physical therapy to "...transfer only-bed, wheelchair, commode-no ambulation."
A progress note by PTA E, dated 6/06/12 at 8:30 AM, stated Patient #30 completed leg exercises times 10 repetitions and ambulated 6 to 8 feet with a front wheeled walker. The note stated Patient #30 was putting some weight on her leg. The next progress note, also by PTA E in conjuntion with a PTA student, was dated 6/06/12 at 1:15 PM. It stated Patient #30 ambulated 10 feet with a front wheeled walker and put some weight on her foot.
A physician progress note, dated 6/06/12, not timed, stated Patient #30 was up walking. The note stated the physician had requested no ambulation secondary to Patient #30's weight and her inability to cooperate."
Patient #30's PT plan of care was not clear and it was not updated to direct staff not to ambulate her.
The Rehabilitation Manager was interviewed on 6/21/12 beginning at 9:50 AM. He reviewed Patient #30's medical record. He confirmed the therapy plan of care was not clear. He also confirmed the plan of care was not clarified when the physician ordered no weight bearing.
The Rehabilitation Manager stated the CAH had not developed therapy policies. He stated policies defining evaluations, plans of care including updates, and supervision of therapy personnel, including PTAs and students, had not been developed.
The CAH failed to provide Patient #30 with a complete therapy evaluation and plan of care and failed to provide direction to therapy personnel.
2. Patient #20's medical record documented a 55 year old male who was admitted to the CAH on 5/26/12 and was discharged on 5/30/12. He was admitted for a fractured left hip. The hip was surgically repaired on 5/27/12.
Patient #20's "POST-OP TOTAL HIP ORDERS," dated 5/27/12 at 9:00 AM, directed PT to initiate a total hip protocol with weight bearing as tolerated.
A PT evaluation, dated 5/28/12 at 8:20 AM, stated it was not clear what Patient #20's level of function was prior to admission. The evaluation stated Patient #20 sat at the bedside with maximum assistance and was not able to stand. The plan stated "See [patient 2 times per] day-6 days per week for rehab. Will get further clarification on prior level of function."
Patient #20 was seen 4 more times by PT between the evaluation and 5/30/12 at 8:00 AM including once by a PTA on 5/29/12 at 8:30 AM. The 5/29/12 PTA note, under the "Plan" section, called for the patient to go from a supine position to sit on the edge of the bed with maximum assistance of 2 persons. The plan also stated to raise the bed to attempt standing times 2 and stand pivot transfer with maximum assistance of 2.
The Rehabilitation Manager was interviewed on 6/21/12 beginning at 9:50 AM. He reviewed Patient #20's medical record. He confirmed the therapy evaluation and plan of care were not clear.
The CAH failed to provide Patient #20 with a complete therapy evaluation and plan of care. Since the CAH did not have PT policies, it was not clear if the PTA was allowed to modify the plan of care.
3. Patient #29's medical record documented a 37 year old male who was admitted to the CAH on 6/02/12 and was discharged on 6/06/12. He was admitted for a stroke.
Patient #29's "GENERAL MEDICAL ADMISSION ORDERS," dated 6/02/12 at 11:40 PM, directed PT and OT were to evaluate and treat the patient. Another order, dated 6/04/12 at 4:15 PM stated to transfer Patient #29 to the medical floor and have PT and OT evaluate and treat the patient.
A PT evaluation, dated 6/05/12 at 8:25 AM, stated PT would see Patient #29 2 times a day for strengthening and gait. He was seen by PT 2 times on 6/05/12 and once on 6/06/12.
An OT evaluation was not documented.
The Rehabilitation Manager was interviewed on 6/21/12 beginning at 9:50 AM. He reviewed Patient #20's medical record. He confirmed the OT evaluation had not been completed. He stated he did not know why the evaluation had not been done.
The CAH failed to conduct an OT evaluation for Patient #29.
4. Patient #37's medical record documented a 77 year old male who was admitted to the CAH on 4/22/12 and was discharged on 4/27/12. He had gall bladder surgery on 4/23/12. He also had a diagnosis of lung disease and received 3 units of red blood cells during his stay.
Patient #37's physician orders, dated 4/22/12 at 8:05 PM, stated to administer oxygen as needed, using at least 2 liters per minute when in bed. Another order, dated 4/24/12 at 9:05 AM, called for PT to evaluate and treat him.
A PT evaluation, dated 4/24/12 at 1:40 PM, stated he was using oxygen at 3 liters per minute. The plan was to see him 2 times a day "...for strengthening in gait & transfers." A specific plan was not documented. The plan did not address the use of oxygen.
A PT note, dated 4/25/12 at 7:50 AM, stated the therapist ambulated Patient #37 with 5 liters of oxygen and his oxygen saturation rate dropped to 77%. A PT note, dated 4/25/12 at 1:00 PM, stated the therapist ambulated him with 8 liters of oxygen and his oxygen saturation rate dropped to 82%. A PT note, dated 4/26/12 at 8:15 AM, stated the therapist ambulated him with 8 liters of oxygen and his oxygen saturation rate dropped to 84%. A PT note, dated 4/27/12 at 7:35 AM, stated the therapist ambulated him with 4 liters of oxygen but did not document his oxygen saturation rates. A PT note, dated 4/27/12 at 1:30 PM, stated the therapist ambulated him with 8 liters of oxygen but did not document his oxygen saturation rates.
The Rehabilitation Manager was interviewed on 6/21/12 beginning at 9:50 AM. He reviewed Patient #37's medical record. He confirmed the plan of care was not clear.
The CAH failed to provide Patient #37 with a complete therapy plan of care.
Tag No.: C0276
Based on staff interview and review of medical records and hospital policies, it was determined the CAH failed to ensure the rules for dispensation and administration of drugs and biologicals included a system to reconcile documented allergies for 1 of 20 patients (#4) whose records were reviewed. This failure had the potential to result in administration of medications that patients' were allergic to. Findings include:
Patient #4's medical record documented an 89 year old female who presented to the ED on 6/15/12 at 5:51 PM, with a complaint of weakness. The "ED Physician Worksheet" documented Patient #4's past medical history included type 2 diabetes, hypertension, asthma, glaucoma, low back pain and degenerative arthritis. The "ED Physician Worksheet" also documented Patient #4 was allergic to the following: "Codeine, Sulfanilamide, Meperidine HCL, Amitriptyline Hcl, Minocycline Hcl, Aspirin, Morphine and Soma (Carisoprodol.)"
The "GENERAL MEDICAL ADMISSION ORDERS," signed by the admitting physician, and dated 6/15/12 at 5:51 PM, documented Patient #4 was allergic only to "Sulfa." The admission orders also included an order for "Morphine Injection 1-2 mg IV every 15 minutes PRN severe pain. Limit 10 mg per 4 hours."
A computer-generated "MEDICAL PROGRESS NOTE," dated 6/18/12 at 7:00 AM to 6/19/12 at 6:59 AM, differed from the allergy list on the "GENERAL MEDICAL ADMISSION ORDERS" and documented Patient #4 was allergic to "Morphine; Minocycline Hcl; Amitriptyline Hcl; Meperidine Hcl; Sulfanilamide; Sulfamethoxazole; Aspirin; Codeine; Meperidine; Minocycline; Amitriptyline; Carisoprodol." The characteristics of allergy symptoms related to these medications were not documented. The same "MEDICAL PROGRESS NOTE" also documented a PRN list of medications and include injectable Morphine Sulfate, 2 mg IV, PRN, every 5 minutes.
A "MEDICATIONS GIVEN REPORT," dated 6/16/12 at 6:01 AM to 6/20/12 at 6:00 AM, documented Morphine Sulfate, 2 mg, was administered to Patient #4 at 3:30 AM and 4:46 AM on 6/17/12. On 6/19/12, the report documented Morphine Sulfate was administered on 2 occasions; 2 mg at 3:08 PM and 1 mg at 4:31 PM. However, no documented allergic reaction to Morphine Sulfate was found in the medical record.
An RN caring for Patient #4 was interviewed on 6/19/12 at 9:00 AM. The RN reviewed Patient #4's EMR and confirmed morphine was listed as an allergy and ordered as a PRN medication for pain control. The medication administration record in the EMR documented morphine was last administered to Patient #4 on 6/18/12 at 4:30 PM. The RN was unable to explain the discrepancies in the medical record related to documented allergies.
The Director of Pharmacy was interviewed on 6/20/12 at 2:44 PM. He reviewed Patient #4's medication record and confirmed the discrepancies related to documentation of allergies. He stated CAH staff were very familiar with Patient #4 as she had been a patient in the facility many times over the past several years. The Director of Pharmacy explained that he believed many of the medications on Patient #4's medication list were not true allergies, rather they upset her digestive system. He confirmed there was no documented procedure in place to efficiently reconcile various allergy lists that potentially exist in patients' records.
There was no documentation in Patient #4's medical record to indicate the pharmacist alerted the physician to the morphine allergy prior to dispensing the medication.
Patient #4 was administered a medication she was identified as being allergic to, potentially placing her health at risk.
Tag No.: C0278
Based on observation, interview, and review of facility policies, it was determined the facility failed to ensure hand hygiene was completed in accordance with nationally recognized standards of practice. This directly impacted 1 of 1 patient (#36) whose surgery was observed and had the potential to impact all surgery patients. Failure to appropriately perform hand hygiene between glove changes had the potential to result in cross contamination and impede infection prevention. Findings include:
1. Patient #36 was a 68 year old female admitted to the facility on 6/20/12 for surgery to remove her uterus and ovaries. Her medical record contained an H&P completed by the surgeon on 6/18/12. The surgeon indicated Patient #36 had a history of pelvic pain, asthma, hypertension, genital herpes, and sleep apnea.
Patient #36's surgery was observed by two surveyors on 6/20/12, from her arrival in the operating room at 8:55 AM through 9:40 AM. RN A and RN B were both present in the operating room and functioning as circulating nurses. At 9:10 AM, RN A was observed to use an electric razor to partially shave Patient #36's abdominal/pelvic region. RN A was then observed to open a package containing a pair of sterile gloves, Betadine solution, and sponges, including at least two sponges mounted on wands. RN A donned the sterile gloves and began to use the sponges to clean Patient #36's inner thighs and genital region. RN A used the sponges on the wands to clean the vaginal region. Once the entire pelvic area was thoroughly cleaned using the Betadine, RN A removed her gloves and immediately donned a second pair of sterile gloves. RN A then inserted a Foley catheter in Patient #36. At 9:25 AM, RN A put the supplies used in the trash, removed her gloves, and donned a pair of clean gloves. At 9:29 AM, RN A was observed to manipulate various equipment cords and position foot pedals on the floor under the operating table. Once equipment was arranged, RN A stood back to wait for the next task. RN A was not observed to perform hand hygiene after shaving Patient #36 and before donning gloves to use the Betadine solution to prepare the pelvic area for surgery. RN A was not observed to perform hand hygiene before donning sterile gloves to insert the Foley catheter or after removing the sterile gloves and before donning clean gloves to handle equipment. RN A was not observed to remove her gloves after manipulating equipment on the floor or apply clean gloves in preparation for the next task.
The CAH's "Hand Hygiene Policy," dated 10/2009, contained instructions for hand hygiene using soap and water and alcohol based hand rub. According to the policy, "If hands are not visibly soiled, hand hygiene can be performed by either washing with soap-and-water or by using an alcohol-based hand rub in the following instances:...Before inserting invasive devices such as Foley [urinary] catheters and peripheral intravascular catheters...When moving from a contaminated body site to a clean body site during patient care...After removing gloves." The policy indicated one of the primary sources of information was the "Centers for Disease Control (CDC) Guideline for Hand Hygiene in Health-Care Settings, 2002."
According to the CDC "Guidelines for Hand Hygiene in Health-Care Settings," dated 10/25/02, "Personnel should be informed that gloves do not provide complete protection against hand contamination. Bacterial flora colonizing patients may be recovered from the hands of [equal to or greater than] 30% of HCWs [Health Care Workers] who wear gloves during patient contact. Further, wearing gloves does not provide complete protection against acquisition of infections caused by hepatitis B virus and herpes simplex virus. In such instances, pathogens presumably gain access to the caregiver's hands via small defects in gloves or by contamination of the hands during glove removal." The document also included data comparing the barrier integrity of various gloves, "In published studies, vinyl gloves have had defects more frequently than latex gloves, the difference in defect frequency being greatest after use...Limited studies indicate that nitrile gloves have leakage rates that approximate those of latex gloves...Although recent studies indicate that improvements have been made in the quality of gloves, hands should be decontaminated or washed after removing gloves."
RN B was interviewed on 6/20/12 at 2:00 PM. The topic of hand hygiene during the procedure, especially related to preparing the skin for surgery, was discussed. RN B stated that when the vaginal area was cleaned using the Betadine and sponges on the wands, then the gloves remained sterile and did not necessarily need to be changed prior to placing the Foley catheter. She confirmed that if the regular sponges were used in addition to the sponges on the wands, the gloves needed to be changed prior to inserting the Foley catheter. She stated she was not aware that staff had been educated to perform hand hygiene between glove changes.
The Infection Preventionist and the Nursing Administrator were interviewed together on 6/21/12 at 1:50 PM. Both confirmed that staff were expected to perform hand hygiene between glove changes. In addition, the Nurse Administrator stated she would expect that gloves always be changed (and hand hygiene performed) between the process of preparing the vaginal area for surgery and placing the Foley catheter.
The facility failed to ensure hand hygiene was performed in accordance with the established policy.
Tag No.: C0302
Based on observation, interview, and review of medical records, it was determined the CAH failed to ensure records were accurate for 1 of 1 patient (#36) whose surgery was observed. Failure to ensure accurate documentation had the potential to interfere with quality, safety, and coordination of patient care. Findings include:
Patient #36 was a 68 year old female admitted to the facility on 6/20/12 for surgery to remove her uterus and ovaries. Her medical record contained an H&P completed by the surgeon on 6/18/12. The surgeon indicated Patient #36 had a history of pelvic pain, asthma, hypertension, and sleep apnea.
Patient #36's record contained a form titled, "History and Physical Update." A pre-printed note on the form read, "The History and Physical was reviewed, the patient was examined, and no change has occurred in the patient's condition since the History and Physical was completed." The surgeon signed this form on 6/20/12 at 8:20 AM.
Patient #36's record also contained a form titled, "ANESTHESIA PROGRESS NOTES." On this form the CRNA documented a pre-surgical assessment which included a review of Patient #36's medical history, allergies, medications, and a physical exam. The CRNA documented that Patient #36's lungs were "CTAB [clear to auscultation (listening with a stethoscope) bilaterally]" and that her heart rate was in "NSR [normal sinus rhythm]." The CRNA indicated general anesthesia was planned for Patient #36. The CRNA documented the assessment was completed on 6/20/12 at 8:25 AM.
On 6/20/12, from 7:45 AM to 9:35 AM, two surveyors observed the pre-operative and intraoperative care for Patient #36. At 8:10 AM, the surgeon arrived to speak with Patient #36 and her family. The surgeon asked if there had been any changes in Patient #36's medical history or medications. He reviewed the plan for surgery and the risks and benefits of the proposed plan. The surgeon was not observed to physically examine Patient #36, such as listening to her heart and lungs with a stethoscope.
At 8:24 AM, the CRNA was observed to introduce himself to Patient #36. He asked Patient #36 if she had any prior issues with anesthesia and Patient #36 told him that during a previous surgery she was paralyzed but still able to hear conversations around her and felt the incision being initiated. The CRNA asked Patient #36 if her blood pressure and asthma were controlled by medications. Patient #36 reported she had been hospitalized twice in the last two years for asthma related issues but that her blood pressure and asthma seemed to be managed by the current medication regimen. The CRNA was not observed to complete a physical examination on Patient #36, such as listening to her heart and lungs.
Patient #36's surgeon was interviewed on 6/20/12 at 2:25 PM. He reviewed his process for assessing a patient prior to surgery. He stated he typically saw a patient in his office within a week prior to surgery. While in the office he obtained a thorough history (such as medical, family, and social history) and completed a detailed physical examination. He stated the day of surgery he visited with patients and asked if there had been any changes in medical history or medications since the office visit. He stated if the patient relayed that anything had changed he would adjust his pre-operative assessment to include listening to heart and lungs if necessary or even canceling surgery if he deemed it unsafe. He confirmed that he had completed a full H&P on Patient #36 two days prior to surgery and that Patient #36 stated there were no changes in those two days.
Patient #36's CRNA was interviewed on 6/20/12 at 2:30 PM. He explained his pre-operative patient assessment. He stated he reviewed the patient's medical information, physician orders, consent, labs, and diagnostic testing prior to actually speaking with the patient. He stated he routinely asked patients if they had any issues with prior anesthesia, explained his plan for sedation, and explained what the patient could expect on waking up from anesthesia. He stated he would usually listen to a patient's heart and lungs if any concern was noted. He confirmed he did not listen to Patient #36's heart and lungs because Patient #36 said she was not having any problems. The CRNA explained that he listened to the lungs after he intubated a patient to ensure adequate ventilation.
The Quality Coordinator was interviewed on 6/22/12 at 8:40 AM. She reviewed Patient #36's medical record. She confirmed that based on the CRNA documentation on the "ANESTHESIA PROGRESS NOTES," it appeared the CRNA completed a physical examination which included listening to Patient #36's heart and lungs prior to surgery.
The facility failed to ensure accurate documentation of a pre-operative assessment for Patient #36.
Tag No.: C0322
Based on observation, interview, and review of medical records, it was determined the facility failed to ensure that, prior to surgery or a procedure, patients were examined to evaluate the potential risks. This impacted 1 of 1 patient (#36) whose surgery was observed, and 3 of 3 sample patients (#9, #34, and #39) who had pain procedures. Failure to ensure an adequate pre-procedure examination had the potential to result in negative patient outcome. Findings include:
1. Patient #36 was a 68 year old female admitted to the facility on 6/20/12 for surgery to remove her uterus and ovaries. Her medical record contained an H&P completed by the surgeon on 6/18/12. The surgeon indicated Patient #36 had a history of pelvic pain, asthma, hypertension, and sleep apnea.
On 6/20/12, from 7:45 AM to 9:35 AM, two surveyors observed the pre-operative and intraoperative care for Patient #36. At 8:10 AM, the surgeon arrived to speak with Patient #36 and her family. The surgeon asked if there had been any changes in Patient #36's medical history or medications. He reviewed the plan for surgery and the risks and benefits of the proposed plan. The surgeon was not observed to perform a physican examination on Patient #36 such as listening to her heart and lungs with a stethoscope.
At 8:24 AM, the CRNA was observed to introduce himself to Patient #36. He asked Patient #36 if she had any prior issues with anesthesia and Patient #36 told him that during a previous surgery she was paralyzed but still able to hear conversations around her and felt the incision being initiated. The CRNA asked if Patient #36 if her blood pressure and asthma were controlled by medications. Patient #36 stated she had been hospitalized twice in the last two years for asthma related issues but that her blood pressure and asthma seemed to be managed by the current medication regimen. The CRNA was not observed to complete a physical examination on Patient #36, such as listening to her heart and lungs.
Patient #36's surgeon was interviewed on 6/20/12 at 2:25 PM. He reviewed his process for assessing a patient prior to surgery. He stated he typically saw a patient in his office within a week prior to surgery. While in the office he obtained a thorough history (such as medical, family, and social history) and completed a detailed physical examination. He stated the day of surgery he visited with patients and asked if there had been any changes in medical history or medications since the office visit. He stated if the patient relayed that anything had changed he would adjust his pre-operative assessment to include listening to heart and lungs if necessary or even canceling surgery if he deemed it unsafe. He confirmed that he had completed a full H&P on Patient #36 two days prior to surgery and that Patient #36 stated there were no changes in those two days.
Patient #36's CRNA was interviewed on 6/20/12 at 2:30 PM. He explained his pre-operative patient assessment. He stated he reviewed the patient's medical information, physician orders, consent, labs, and diagnostic testing prior to actually speaking with the patient. He stated he routinely asked patients if they had any issues with prior anesthesia, explained his plan for sedation, and explained what the patient can expect on waking up from anesthesia. He stated he would usually listen to a patient's heart and lungs if any concern was noted. He confirmed he did not listen to Patient #36's heart and lungs because Patient #36 said she was not having any problems. The CRNA explained that he listened to the lungs after he intubated a patient to ensure adequate ventilation.
The facility failed to ensure Patient #36 was examined prior to her surgery to evaluate the risk of anesthesia and the procedure.
2. Patient #39 was admitted on 6/04/12 for a right lumbar transforaminal steroid injection. The "PROCEDURE SEDATION RECORD" indicated an RN administered Versed 1 mg IV at 2:20 PM, and that Patient #34 was placed on Oxygen at 2 liters per minute via a nasal cannula from 2:18 PM to 2:23 PM.
Patient #39's record contained an H&P completed by the physician on 5/21/12. The physician's documentation included Patient #39's past medical and surgical history, a review of systems, and a physical examination. Under the section regarding "Review of Systems," the physician noted Patient #39 denied fevers, chills, night sweats, and unintentional weight loss or gain. The physician also noted Patient #39 denied loss of ability to control bowel and bladder. In the section for "Physical Exam," the physician noted Patient #39 was a "Pleasant gentleman in no acute distress," was "Normocephalic," and "He can sit, stand and ambulate independently. Lumbar range of motion is reduced and he has increased pain with flexion." The physician did not document an assessment that included evaluating Patient #39's heart and lungs with a stethoscope.
Patient #39's record contained a form titled, "History and Physical Update." A pre-printed note on the form read, "The History and Physical was reviewed, the patient was examined, and no change has occurred in the patient's condition since the History and Physical was completed." The physician signed this form on 6/04/12 at 2:15 PM. The medical record did not contain evidence of an examination immediately prior to the procedure to evaluate the potential risks.
3. Patient #9 was a 91 year old male admitted on 6/18/12 for a lumbar epidural steroid injection. The "PROCEDURE SEDATION RECORD" indicated an RN administered Versed 1 mg IV at 1:57 PM, and that Patient #9 was on 3 liters per minute of Oxygen via nasal cannula from 2:00 PM to 2:05 PM and again at 2:20 PM.
Patient #9's medical record contained an H&P completed by the physician on 6/04/12. The physician documented Patient #9 had a history of a kidney tumor and diabetes. Under the "Physical Exam" section, the physician documented, "Pleasant 91-year-old man in no acute distress," and "He can sit, stand, and ambulate. Palpation of his lower back is negative. He complains of pain in the left gluteal region and somewhat over the great trochanter area." The physical examination did not include listening to Patient #9's heart and lungs with a stethoscope, or address body systems such as the neurological system, or the genitourinary, or gastrointestinal system.
Patient #9's record contained a form titled, "History and Physical Update." A pre-printed note on the form read, "The History and Physical was reviewed, the patient was examined, and no change has occurred in the patient's condition since the History and Physical was completed." The physician signed this form on 6/18/12 at 1:50 PM. The medical record did not contain evidence of an examination immediately prior to the procedure to evaluate the potential risks.
4. Patient #34 was a 53 year old female admitted on 6/04/12 for a lumbar epidural steroid injection. The "PROCEDURE SEDATION RECORD" indicated an RN administered Versed 2 mg IV at 1:15 PM, and that Patient #34 was on 2 liters per minute of Oxygen via nasal cannula from 1:14 PM to 1:19 PM.
Patient #34's medical record contained an H&P completed by the physician on 5/21/12. The physician documented Patient #34's medical history included obesity, right-sided paralysis, seizure disorder, asthma, hypertension and stage III chronic kidney disease. Under the section regarding "Review of Systems," the physician noted Patient #34 denied fevers, chills, night sweats, and unintentional weight loss or gain. The physician also noted Patient #34 denied loss of ability to control bowel and bladder. Under the "Physical Exam" section, the physician documented "Pleasant severely morbidly obese female..." and noted Patient #34 could, "sit, stand and ambulate independently." The physical examination did not include listening to Patient #34's heart and lungs with a stethoscope or addressing other body systems such as the neurological system.
Patient #34's record contained a form titled, "History and Physical Update." A pre-printed note on the form read, "The History and Physical was reviewed, the patient was examined, and no change has occurred in the patient's condition since the History and Physical was completed." The physician signed this form on 6/04/12 at 1:12 PM. The medical record did not contain evidence of an examination immediately prior to the procedure to evaluate the potential risks.
The Medical Director was interviewed on 6/21/12 at 3:00 PM. He reviewed the records for Patients #9, #34, and #39 and confirmed the lack of a documented examination prior to the procedure to evaluate the risk of the procedures that were performed and the administration of the sedative medication. He stated he would have expected to see documentation of a pre-procedure assessment.
The facility failed to ensure patients were adequately examined to evaluate the risks of the procedures to be performed.