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Based upon observation, interview and record review, the hospital failed to ensure a nursing care plan had been developed for 2 of 2 patients in the 24 Hour Care Unit (Patients P-1 and P-2). Findings include:

Patients P-1 and P-2 did not have a nursing care plan that included identified patient problems, specific interventions and patient goals.

P-1 was admitted to the 24 Hour Care Unit on 11/30/2010 after undergoing a laparoscopic gastric banding and hiatal hernia repair. The "Outpatient/AM Admit Admission Pathway", dated 11/30/2010, indicated P-1 had diagnoses that included sleep apnea. There was no nursing care plan to address identified problems, interventions and patient goals.

The Director of Surgical Services was interviewed on 12/1/2010, at 10:10 AM and stated that nursing staff utilized standards of care individualized the care plan if the patient did not meet baseline within the standards of care. The "Perioperative Standards of Care Outpatient (Postoperative)" and the "Standards of Care Surgical Overnight Observation" were reviewed and were not signed and were not present on the patient's chart. Registered Nurse (RN)-E, who was caring for P-1, was interviewed on 12/1/2010 at 11:15 AM and verified the lack of a nursing care plan for P-1.

P-2 was admitted to the 24 Hour Care Unit on 11/30/2010, following a Whipple procedure for pancreatic cancer. The "Outpatient/AM Admission Pathway", dated 11/29/2010 and 11/30/2010, indicated P-2 was 77 years old and had coronary artery disease, cardiac arrhythmias, low back pain due to spinal stenosis and chronic renal disease. P-2 had Diabetes Mellitus which was controlled by diet and had recent significant weight loss. P-2 was also identified at high risk for skin impairment due to his age, Diabetes, peripheral vascular disease, and an operative procedure lasting longer than four hours. The pathway indicated the "OP Time High Risk Skin Alert" had been initiated. Although nursing staff had initiated the "Adult ICU Patient Standard of Care" it was not individualized and did not address diabetes, nutritional status, history of back pain or increased risk of skin breakdown. RN-E was interviewed on 12/1/2010 at 11:15 AM and stated a care plan should have been developed to address the patient's skin risk factors, nutrition and mobility.

The Director of Surgical Services was interviewed on 12/1/2010 at 10:10 AM and stated the 24 Hour Care Unit was utilized for patients who required more nursing care than they may receive on a general nursing unit but not as much care as they would receive in an intensive care unit. She verified the length of stay for patients within the unit was 24 hours or less. After review of the patient record, she stated the patient did not meet baseline in several areas of the standard of care and the care plan should have been developed to include identified patient problems, interventions and goals.

Based on observation, interview and review of hospital policy, the hospital failed to ensure anesthesia drugs in 3 of 5 anesthesia carts observed were kept locked and in a secure area. Findings include:

Anesthesia drugs located in mobile anesthesia carts in operating room #20 in the Surgical Suite and in one operating room in The Birth Place were not locked or stored in a secure area when not in use.

During a tour of the surgical suite on 11/30/2010, at 1:00 PM, an anesthesia cart containing numerous anesthetic medications was observed unlocked in operating room #20. The operating room was located near the end of a hallway and no staff were present in the area. The Director of Surgical Services was interviewed at that time and stated anesthesia carts were to be locked when staff were not present. She stated the operating room was staffed twenty four hours a day; however, housekeeping staff were responsible for the terminal cleaning of the operating rooms within the surgical suite and were not supervised when in the department.

During a tour of the operating room suite located in The Birth Place on 11/30/2010 at approximately 3:15 PM, an anesthesia cart containing numerous anesthetic drugs and agents was observed unlocked. There were no staff present in the operating room suite. The Director of Surgical Services was interviewed at approximately 3:35 PM and stated the anesthesia carts were to be kept locked when staff were not present. The Director of Women's and Children's Services was interviewed on 12/1/2010 at approximately 9:30 AM and stated housekeeping staff had access to the operating room suite without supervision.

The Pharmacist responsible for the satellite pharmacy within the Surgical Suite was interviewed on 12/2/2010 at 9:30 AM and provided a list of the medications stored within the anesthesia carts including thirty-five different anesthetic drugs such as Propofol (anesthetic medication), Succinylcholine (a muscle relaxant) and Esmolol (cardiac medication).

The hospital policy "Orientation to the Department of Anesthesia", last reviewed 2/2007, indicated anesthesia carts should be locked at the end of the day. The Director of Anesthesia was interviewed on 11/30/2010 at 2:30 PM and stated anesthesia carts were to be locked whenever anesthesia staff were not present.


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Anesthesia drugs and agents in one Endoscopy clinic anesthesia cart were not not kept locked in a secure area when not in use.

During tour of the Endoscopy clinic treatment rooms on 12/1/2010 at 2:20 p.m., the anesthesia cart in room 5 was noted to be unlocked and unattended by staff. The room was near the end of a hallway and no staff were noted in the hallway area at the time. The Endoscopy Clinic Director verified the cart was unlocked and that procedures in the room were concluded for the day. The director also verified the cart contained anesthetic agents and some controlled substances in a separate, but small locked box and reported the anesthesia cart should have been locked at the time.

The director was requested to provide a listing of the drugs and agents in the cart and variances noted during the tour. The list of medications stored in the anesthesia cart, provided on 12/2/10 at 9:30 a.m., included Lidocaine and pre-drawn syringes of Propofol and Robinul. There were up to 35 drugs and agents included on the formulary of items potentially located in the cart. In addition, narcotic agents in the small locked box included Fentanyl and Versed. The surgical pharmacist verified on 12/2/10 at 10:30 a.m. the listing of drugs and agents in the anesthesia cart and reported the department was preparing to employ a more secure narcotic box that could be mechanically fastened to the anesthesia cart.

The facility policy Surgical Services-Anesthesia #3.8.2 included an end of the day routine that included , "Lock anesthesia cart... narcotics locked up."

Based upon interview and record review, the hospital failed to ensure a post anesthesia evaluation was completed within 48 hours of procedures for 4 of 4 patients who had been transferred from the surgical suite directly to an intensive care unit (ICU) following their surgical procedure (Patients P-3, P-4, P-6, and P-5). Findings included:

Patient P-3 was admitted to the Surgical Intensive Care Unit (SICU) on 11/29/2010 immediately following an aortic valve replacement and four coronary artery bypass grafts under general anesthesia. The only post-anesthesia note on the medical record was completed upon admission to the SICU and the anesthesiologist documented P-3's blood pressure, pulse, ventilator/respiratory status and level of consciousness. The anesthesiologist also indicated P-3 had no immediate anesthetic complications. Chart review on 11/30/2010 and on 12/2/2010 indicated no further post-anesthesia evaluation by an anesthesiologist to assess respiratory status, cardiovascular function, mental status, temperature, pain, nausea or vomiting, hydration status, or other complications related to anesthesia. This was verified by the Clinical Nurse Specialist of the SICU on 12/2/2010 at 9:15 AM.

Patient P-4 was admitted to the SICU on 11/30/2010 immediately following a coronary artery by pass graft under general anesthesia. The only post-anesthesia note on the patient chart was completed by the anesthesiologist upon admission to the SICU and indicated P-4's blood pressure, oxygen saturation, level of consciousness and stable condition upon transfer. Chart review on 12/2/2010 indicated there was no further post-anesthesia evaluation. The Clinical Nurse Specialist in SICU was interviewed on 12/2/2010 at 9:15 AM and stated P-4 was not seen by an anesthesiologist to assess respiratory status, cardiovascular function, mental status, temperature, pain, nausea or vomiting, hydration status, or other complications related to anesthesia.

Patient P-6 was admitted to the SICU on 11/15/20110 immediately following a thoracotomy under general anesthesia to repair a torn esophagus. The only post-anesthesia evaluation was completed immediately upon admission to SICU and included documentation of the patient's blood pressure, oxygen saturation, pulse and sedated mental status. A review of the patient's medical record on 12/1/2010 at 3:20 PM (16 days following surgery) revealed there had been no further post-anesthesia evaluation of the patient by an anesthesiologist to assess respiratory status, cardiovascular function, mental status, temperature, pain, nausea or vomiting, hydration status, or other complications related to anesthesia. This was verified by the Clinical Nurse Specialist of the SICU.

The SICU Clinical Nurse Specialist and the Interim Nurse Manager of the SICU were interviewed on 12/1/2010 at 9:15 AM. They stated Anesthesiologists rarely saw the patients that had procedures with a general anesthesia to complete a post-anesthesia evaluation in the SICU. They stated this practice had caused communication issues between nursing staff and anesthesia staff.

A review of the hospital policy "Anesthesia Governing Policies", last reviewed/revised 1/10, indicated post anesthesia visits with documentation approximately 24 hours after anesthesia recovery would be completed for all inpatients. The policy indicated members of the anesthesia department, including Certified Registered Nurse Anesthetists (CRNA) and Anesthesiologists, would work together to accomplish the 24 hour visit. The policy indicated there would be documentation on the anesthesia record to include the date, time and course of anesthesia recovery.

The Chief of Anesthesiology was interviewed on 12/1/2010 at approximately 10:50 AM. He stated the policy of the Department of Anesthesiology directed surgical patients would have a post-anesthesia visit within 48 hours of surgery and a note would be made on the anesthesia record to indicate if the patient had any complications related to anesthesia. He stated the post-anesthesia evaluation by an anesthesiologist was usually completed prior to a patient's discharge from the Post Anesthesia Care Unit (PACU). He stated patients who had undergone cardiac surgery and other types of extensive surgeries were not admitted to PACU but were transferred directly to an intensive care unit.


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P-5 did not have a post anesthesia evaluation documented in the medical record within 48 hours following surgery.

Review of the medical record revealed that P-5 received surgical services under a general anesthesia on 11/29/2010. The surgical record identified an anesthesia stop time of 9:08 p.m. on 11/29/2010. The post anesthesia section of the surgical record identified "Patient transported directly to ICU" and was signed by the anesthesiologist on 11/29/10 at 9:08 p.m. There was no evidence that the anesthesiologist had completed a post anesthesia assessment that included respiratory function, including respiratory rate, airway patency, and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; and postoperative hydration.