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Based on review of nursing staff schedules, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to adhere to facility policy and procedure for staffing levels and type of nursing personnel for 3 of 3 months in 2022 (October 1- December 31, 2022) reviewed and for 10 of 10 months in 2023 (January 1 - October 17, 2023) reviewed. This failed practice had the potential to affect all patients of the CAH. The CAH (October 1 - December 31, 2022) had 65 patients (Inpatient, observation and outpatient services). The CAH (January 1 - October 17, 2023) had 428 patients (Inpatient, observation and outpatient services).

Findings are:

A. Review of the policy and procedure titled Nursing Staff Plan (Last Approved 10/2/2023) stated "1. Three licensed Registered Nurses are present in the Acute/ED (Emergency Department) unit of the hospital at all times."

B. Review of the October 1 - 31, 2022 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (10 of 31 night shifts) per facility policy and procedure on the following dates:
10/1/22 - 2 RN's
10/3/22 - 2 RN's and 1 Paramedic
10/4/22 - 2 RN's and 1 Paramedic
10/5/22 - 2 RN's and 1 Paramedic
10/6/22 - 2 RN's and 1 Paramedic
10/10/22 - 2 RN's and 1 Paramedic
10/11/22 - 2 RN's and 1 Paramedic
10/13/22 - 2 RN's and 1 Paramedic
10/14/22 - 1 RN and 2 Paramedics
10/22/22 - 1 RN and 1 Paramedic

-Review of the November 1 - 30, 2022 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (4 of 30 night shifts) per facility policy and procedure on the following dates:
11/10/22 - 1 RN and 1 Paramedic
11/21/22 - 2 RN's and 1 Paramedic
11/22/22 - 2 RN's and 1 Paramedic
11/30/22 - 2 RN's and 1 Paramedic

-Review of the December 1 - 31, 2022 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (6 of 31 night shifts) per facility policy and procedure on the following dates:
12/5/22 - 2 RN's and 1 Paramedic
12/10/22 - 2 RN's
12/11/22 - 2 RN's and 1 Paramedic
12/22/22 - 2 RN's and 1 Paramedic
12/24/22 - 2 RN's and 1 Paramedic
12/25/22 - 2 RN's and 1 Paramedic

-Review of the January 1 - 31, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (10 of 31 night shifts) per facility policy and procedure on the following dates:
1/1/23 - 2 RN's and 1 Paramedic
1/2/23 - 2 RN's and 1 Paramedic
1/3/23 - 2 RN's and 1 Paramedic
1/4/23 - 2 RN's and 1 Paramedic
1/12/23 - 2 RN's and 1 Paramedic
1/14/23 - 2 RN's and 1 Paramedic
1/15/23 - 2 RN's and 1 Paramedic
1/20/23 - 2 RN's and 1 Paramedic
1/23/23 - 2 RN's and 1 Paramedic
1/24/23 - 2 RN's and 1 Paramedic

-Review of the February 1 - 28, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (17 of 28 night shifts) per facility policy and procedure on the following dates:
2/1/23 - 2 RN's and 1 Paramedic
2/3/23 - 2 RN's and 1 Paramedic
2/4/23 - 2 RN's and 1 Paramedic
2/5/23 - 2 RN's and 1 Paramedic
2/7/23 - 2 RN's and 1 Paramedic
2/10/23 - 2 RN's and 1 Paramedic
2/13/23 - 2 RN's and 1 Paramedic
2/14/23 - 2 RN's and 1 Paramedic
2/15/23 - 2 RN's and 1 Paramedic
2/16/23 - 2 RN's and 1 Paramedic
2/20/23 - 1 RN and 1 Paramedic
2/22/23 - 2 RN's and 1 Paramedic
2/24/23 - 2 RN's and 1 Paramedic
2/25/23 - 2 RN's and 1 Paramedic
2/26/23 - 2 RN's and 1 Paramedic
2/27/23 - 2 RN's and 1 Paramedic
2/28/23 - 2 RN's and 1 Paramedic

-Review of the March 1 - 31, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (7 of 31 night shifts) per facility policy and procedure on the following dates:
3/3/23 - 2 RN's and 1 Paramedic
3/5/23 - 2 RN's and 1 Paramedic
3/6/23 - 2 RN's and 1 Paramedic
3/7/23 - 2 RN's and 1 Paramedic
3/10/23 - 2 RN's and 1 Paramedic
3/20/23 - 2 RN's and 1 Paramedic
3/27/23 - 2 RN's and 1 Paramedic

-Review of the April 1 - 30, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (11 of 30 night shifts) per facility policy and procedure on the following dates:
4/4/23 - 2 RN's and 1 Paramedic
4/7/23 - 2 RN's and 1 Paramedic
4/8/23 - 2 RN's and 1 Paramedic
4/9/23 - 2 RN's and 1 Paramedic
4/10/23 - 2 RN's and 1 Paramedic
4/11/23 - 2 RN's and 1 Paramedic
4/17/23 - 2 RN's and 1 Paramedic
4/18/23 - 2 RN's and 1 Paramedic
4/19/23 - 2 RN's and 1 Paramedic
4/28/23 - 1 RN and 1 Paramedic
4/29/23 - 1 RN and 1 Paramedic

-Review of the May 1 - 31, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (10 of 31 night shifts) per facility policy and procedure on the following dates:
5/1/23 - 2 RN's and 1 Paramedic
5/12/23 - 2 RN's and 1 Paramedic
5/18/23 - 1 RN and 1 Paramedic
5/19/23 - 2 RN's and 1 Paramedic
5/20/23 - 2 RN's and 1 Paramedic
5/23/23 - 2 RN's and 1 Paramedic
5/24/23 - 2 RN's and 1 Paramedic
5/27/23 - 2 RN's and 1 Paramedic
5/29/23 - 2 RN's and 1 Paramedic
5/31/23 - 1 RN's and 1 Paramedic

-Review of the June 1 - 30, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (8 of 30 night shifts) per facility policy and procedure on the following dates:
6/1/23 - 2 RN's and 1 Paramedic
6/8/23 - 2 RN's and 1 Paramedic
6/9/23 - 2 RN's and 1 Paramedic
6/11/23 - 2 RN's and 1 Paramedic
6/12/23 - 2 RN's and 1 Paramedic
6/20/23 - 2 RN's and 1 Paramedic
6/21/23 - 2 RN's and 1 Paramedic
6/30/23 - 2 RN's and 1 Paramedic

-Review of the July 1 - 31, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (18 of 31 night shifts) per facility policy and procedure on the following dates:
7/1/23 - 2 RN's and 1 Paramedic
7/2/23 - 2 RN's and 1 Paramedic
7/3/23 - 2 RN's and 1 Paramedic
7/6/23 - 2 RN's and 1 Paramedic
7/9/23 - 2 RN's and 1 Paramedic
7/10/23 - 2 RN's and 1 Paramedic
7/11/23 - 2 RN's and 1 Paramedic
7/13/23 - 2 RN's and 1 Paramedic
7/18/23 - 2 RN's and 1 Paramedic
7/19/23 - 2 RN's and 1 Paramedic
7/20/23 - 2 RN's and 1 Paramedic
7/21/23 - 2 RN's and 1 Paramedic
7/22/23 - 2 RN's and 1 Paramedic
7/23/23 - 2 RN's and 1 Paramedic
7/25/23 - 2 RN's and 1 Paramedic
7/26/23 - 2 RN's and 1 Paramedic
7/30/23 - 2 RN's and 1 Paramedic
7/31/23 - 2 RN's and 1 Paramedic

-Review of the August 1 - 31, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (12 of 31 night shifts) per facility policy and procedure on the following dates:
8/1/23 - 2 RN's and 1 Paramedic
8/3/23 - 2 RN's and 1 Paramedic
8/7/23 - 2 RN's and 1 Paramedic
8/11/23 - 2 RN's and 1 Paramedic
8/12/23 - 2 RN's and 1 Paramedic
8/13/23 - 2 RN's and 1 Paramedic
8/14/23 - 2 RN's and 1 Paramedic
8/15/23 - 2 RN's and 1 Paramedic
8/21/23 - 2 RN's and 1 Paramedic
8/22/23 - 2 RN's and 1 Paramedic
8/23/23 - 2 RN's and 1 Paramedic
8/31/23 - 2 RN's and 1 Paramedic

-Review of the September 1 - 30, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (6 of 30 night shifts) per facility policy and procedure on the following dates:
9/1/23 - 2 RN's and 1 Paramedic
9/2/23 - 2 RN's and 1 Paramedic
9/9/23 - 2 RN's
9/21/23 - 2 RN's and 1 Paramedic
9/24/23 - 2 RN's and 1 Paramedic
9/30/24 - 2 RN's and 1 Paramedic

-Review of the October 1 - 17, 2023 nursing staff schedules (7 PM - 7 AM) lacked evidence of three Registered Nurses (RN's) scheduled in the hospital (8 of 17 night shifts) per facility policy and procedure on the following dates:
10/2/23 - 2 RN's and 1 Paramedic
10/3/23 - 2 RN's and 1 Paramedic
10/5/23 - 2 RN's and 1 Paramedic
10/10/23 - 2 RN's and 1 Paramedic
10/12/23 - 2 RN's and 1 Paramedic
10/13/23 - 2 RN's and 1 Paramedic
10/14/23 - 2 RN's and 1 Paramedic
10/16/23 - 2 RN's and 1 Paramedic


C. Interview with the Chief Nursing Officer (10/18/23 at 10:40 AM) confirmed a paramedic was scheduled in place of one of the RN's scheduled.

Based on observations, review of medical staff rules and regulations, record review, policy review, interviews, and job descriptions review, the Critical Access Hospital (CAH) failed to ensure the surgeon completed an updated history and physical or explanation of risk benefits prior to surgery or procedure for 3 (Patients 13, 14, 19) out of 10 surgical records reviewed. The facility failed to provide standard post operative care for 1 (Patients 12) out of 10 surgical records reviewed. This failed practice had the potential to affect all surgical patients presenting to the CAH. The facility had 348 surgical patients for Fiscal Year 2023. The Standard cited C1144 also resulted in the Condition of Participation for Surgical Services to be not met.

This condition is not met as evidenced by:

A. Review of the Medical Staff Rules and Regulations (Last Approved 10/26/2021) titled "History and Physical" revealed, "Surgical operations and potentially hazardous diagnostic procedures shall be cancelled if the history and physical examination is not recorded on the chart in accordance with Section 4.7 ...." Section 4.7 reads, "A complete admission history and physical examination shall be done on each patient and recorded within twenty-four (24) hours of admission." "If a complete history has been recorded and a physical examination performed within thirty (30) days prior to the patient's admission to the Hospital, a reasonably durable and legible copy of these reports may be used in the patient's medical record in lieu of the admission history and report of the physical examination, provided these reports were recorded by a member of the Medical Staff. In such instances, an internal admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded and an update must be performed by a practitioner who is credentialed to provide history and physical examinations within twenty-four (24) hours of admission."

B. Review of Patient 13's medical record (10/18/2023 at 1:01 PM) revealed presented to the CAH on 4/5/2023 at 08:06 AM for an Esophagogastroduodenoscopy (EGD) (A scope tube is inserted through the mouth and down the patients throat to examine the lining of the esophagus, stomach and first part of the small intestine) under Monitored Anesthesia Care (MAC) (procedure start time 9:18 AM) lacked evidence of the time the Updated History and Physical (H&P) was completed and the Risk Benefits explained to the patient prior to the procedure was blank.

-Review of Patient 14's medical record (10/18/2023 at 1:52 PM) revealed presented to the CAH on 4/10/2023 at 7:55 AM for a Colonoscopy (scope/tube inserted into the rectum to view the colon) and Esophagogastroduodenoscopy (EGD) (A scope tube is inserted through the mouth and down the patients throat to examine the lining of the esophagus, stomach and first part of the small intestine) under Monitored Anesthesia Care (MAC) (procedure start time 8:59 AM). The entire medical record lacked evidence the Updated History and Physical and the Risk Benefits explained to the patient was complete prior to procedure (Pre-Op H&P attested/signed 4/10/2023 at 12:25 PM, after the procedure).

-Review of Patient 19's medical record (10/19/2023 at 10:50 AM) revealed presented to the CAH on 10/4/2023 at 6:05 AM for a Colonoscopy (scope/tube inserted into the rectum to view the colon) under Monitored Anesthesia Care (MAC) (procedure start time 7:14 AM) lacked evidence of the time the Updated History and Physical was completed, and the Risk Benefits explained to the patient by the surgeon prior to the procedure was blank.

C. Review of the policy and procedure titled Recovery Room-Post Anesthesia Care Unit (PACU) Patient Care (Last approved 3/13/2023) revealed, "Discharge from PACU to inpatient unit when Certified Registered Nurse Anesthetist (CRNA) designates or when patient meets discharge criteria of 7 or greater on Post Anesthesia Recovery Score." Post Anesthesia Recovery Score includes a scoring system based on activity, respirations, circulation, consciousness, and color. See policy for numbered Post Anesthesia Recovery Score criteria on page 2.

-Review of the Pre-Op and Post-Op General/Ortho Process (last updated 8/24/2022) revealed nursing parameters for post operative care defined by phase one, phase two

-Review of the policy and procedure titled Anesthesia Post-Op Orders (Last Approved 1/13/2022) revealed "Transfer to Post-Op 2 after three sets of VS (vital signs) have been obtained and Aldrete score greater than 8 and the patient does not exhibit severe pain or nausea and any other clinical conditions that were not present preoperatively have been addressed by the anesthesia provider, surgeon, or medical staff."

D. Review of the Registered Nurse-Pre & Post Operative job description (Last revised 8/23/2023) revealed "Understands the anesthesia method used and anesthetic agent's effects. Recognizes symptoms and complications of surgery and anesthesia and provides consequent nursing interventions."

E. Review of Patient 12's medical record (10/19/2023 at 12:15PM) revealed the patient presented to the CAH on 11/2/2022 at 6:00 AM for a Laparoscopic Cholecystectomy (removal of the gallbladder). Review of the pre-operative orders by MD-B lacked evidence of a date and time of signature, and code status area was blank. The Post-Anesthesia evaluation documented by CRNA-F 11/2/2022 at 8:39 AM lacked evidence of a complete pain assessment or Aldrete score. Mental status was documented as, "At pre-operative baseline, Alert and Oriented x4." The Post-Operative record revealed the "Discharge: when criteria is met," was blank (confirmed by RN-A 10/23/2023 at 9:26 AM).

Review of the entire medical record lacked evidence of a notification time or what was reported to MD-B by RN-A [to report the episode of "fainted for 10-20 seconds ....really dizzy" documented by RN-A at 10:25 AM) or continued "lightheaded dizzy, must sit back down" episode documented by RN-A at 12:50 PM]. An interview with RN-A (10/23/2023 at 9:26 AM) revealed RN-A did not recall the time notified or what patient status reported to MD-B but referenced the 11/2/2022 1:15 PM documentation [that did not include a notification time, or what was patient status was discussed between RN-A and MD-B]. An interview with RN-B did not recall being notified of the 3:53 PM lightheaded and dizzy episode documented by another RN while RN-B was in the ED. Review of the entire medical record lacked evidence of the 10:25 AM, 12:50 PM and 3:53 PM above post-operative complication (low fluid volume signs and symptoms) episodes being reported to MD-B.

Review of the entire medical record revealed the CODE button was pressed at 4:42 PM due to an unresponsive episode resulting in the code team to be activated, and an oral airway (tube inserted into the airway to give rescue breaths) to be placed. Patient 12 required Narcan (opioid/pain medication reversal), 3 liters of intravenous (IV) fluids, IV continuous (drip) blood pressure support medication, and 1 unit of blood IV transfusion emergently while at the CAH.

Review of the entire medical record revealed no post-operative labs were checked until 4:45 PM (after the CODE BLUE emergency). Patient 12's lactic acid was 4.7, and hemoglobin (blood oxygen level) was 10.2 leaving the CAH and was 7 on arrival to the acute care accepting facility. The patient was transferred from the CAH via ground ambulance to an accepting acute care facility for emergent surgery on 11/2/2022 with MD-B, documentation revealed 4 liters (severe loss-there is approximately 4-5 liters of blood in the body) of blood and clots were removed from inside the patient and required transfusions of 6 units of blood and 3 units of fresh frozen plasma (clotting factors to help stop an active bleed).

F. Interview with MD-B (10/18/2023 at 11:14 AM) regarding Patient 12's 11/2/2022 stay confirmed that MD-B was the surgeon for the outpatient laparoscopic cholecystectomy (gallbladder removal). MD-B revealed that the surgery was routine without any intraoperative complications, two clips on the cystic artery were placed utilizing the same manufactured single use supplies, instruments and equipment as MD-B always does. MD-B confirmed that post-operative nausea and light headedness was reported by RN-A on 11/2/2022 but did not recall the time. MD-B confirmed that Patient 12 was re-examined by MD-B in the post-operative care unit (PACU) but does not recall time of examination. MD-B recalled that Patient 12 was complaining of lower abdominal cramping pain 2-3/10, and blood pressure was stable, but does not recall if labs were checked post-operatively. MD-B recalled Patient 12 was ordered "extended recovery" to stay for observation either into the afternoon or overnight until discharge criteria was met.

-Interview with MD-C (10/18/2023 at 3:24 PM) regarding Patient 12's 11/2/2022 stay revealed MD-C was not assigned to Patient 12 but was in the inpatient area and responded to the CODE BLUE (quit breathing, medical emergency) to assist. MD-C ordered Narcan (opioid-narcotic pain medication reversal agent) at 4:50 PM for Patient 12, who "came to, breathing, and talking after the Narcan was administered. The patient then complained of Right Upper Quadrant pain which was out of the ordinary for the laparoscopic cholecystectomy (removal of the gallbladder)." MD-C stated it was then decided to initiate hypotension (low blood pressure) and hypovolemia (low blood volume) interventions through intravenous fluids and blood administration. MD-C recalled that MD-B was notified after stabilizing the patient, and initiated transfer to a higher level of care for emergent surgical evaluation via Ambulance.

-Interview with Registered Nurse (RN)-B (10/19/2023 at 8:49 AM) revealed that RN-A told RN-B that there were not enough RNs in the PACU after 3:00 PM on 11/2/2022 and Patient 12 required further monitoring prior to discharge due to Patient 12 reported being dizzy and lightheaded when standing up. RN-B did not recall if patient 12's syncope (passing out when standing up) continued dizzy episodes or nausea was reported in the 2:15 PM handoff between RN-A and RN-B. RN-B revealed they were the charge nurse that day and floated between the emergency department (ED) and inpatient floor; at the time of the CODE BLUE RN-B was in the ED.

-Interview with the Director of Surgical Services (10/19/2023 at 1:18PM) revealed if an outpatient post-surgical patient does not meet discharge criteria before the Post Anesthesia Care Unit (PACU) RNs end of shift, a designated "late person," stays to monitor the patient until criteria is met for discharge. The Director of Surgical Services confirmed that if an outpatient discharge criteria is not met, the surgeon is contacted for an "extended recovery" order. The outpatient is then transferred to the inpatient floor until PACU phase two criteria is met for discharge.

-Interview with the Director of Quality and Compliance (10/19/2023 at 12:26PM) confirmed Patient 12's 11/2/2022 entire stay was not Peer Reviewed.

-Interview with the Chief Nursing Officer (CNO) (10/19/2023 at 1:53 PM) confirmed that there were no incidents, complaints, or grievances filed with the facility from October 2022-October 19, 2023, regarding Patient 12's or the 11/2/2022 entire stay.

-Interview with Certified Registered Nurse Anesthetist (CRNA) (10/23/2023 at 8:25AM) revealed that CRNA-F was not contacted to re-evaluate the patient while in PACU phase two, but did recall Patient 12 appearing pale post-operatively.

-Interview with RN-A (10/23/2023 at 9:26 AM) revealed that RN-A was assigned to Patient 12 in the PACU until the 2:15 PM handoff on 11/2/2022 (patient moved from the PACU area to the inpatient floor for extended recovery, and RN-A gave report/handoff to RN-B). RN-A did not recall specifics of handoff between CRNA-F but did recall Patient 12 reported "post-operative lightheaded and taking a while to recover 10 years ago (last surgery)." RN-A recalled on 11/2/2022 PACU stay, "When the patient stood to use the bathroom, they became lightheaded, pale, sweaty, passed out and required help back into bed. After that episode, every time the patient would change positions, they would feel woozy." RN-A stated Patient 12 met discharge requirements from the PACU, but seemed off and advocated to ask MD-B for an extended stay order.

Based on record review, review of medical staff rules and regulations, policy and procedure review and staff interviews, the Critical Access Hospital (CAH) failed to ensure the Preanesthesia Evaluation that included the physical exam was completed prior to surgery for 4 of 10 (Patients 13, 17, 19, 20) surgical records reviewed. This failed practice had the potential to affect all surgical patients at the CAH. The facility had 348 surgical patients for Fiscal Year 2023. This resulted in the Condition of Participation for Surgical Services to be not met, to include the cited Standard C1144.

Findings are:

A. Review of the Medical Staff Rules and Regulations (Last Approved 10/26/2021) on page 6, titled: Anesthesia Record revealed, "For procedures including major, regional, or monitored anesthesia care, the anesthetist shall be responsible for maintaining a complete and timely anesthesia record, including pre-anesthetic evaluation; all events during induction, maintenance, and emergence; and post-anesthetic follow-up. Pre-anesthetic evaluation must, except in case of extreme emergency, be recorded prior to the patient's transfer to the operating area and before preoperative medication is administered."

-Review of policy titled Anesthesia Evaluation and Assessment (Last approved 6/9/2021) revealed "All patients will be evaluated by the anesthesia staff prior to his/her surgical procedure to determine fitness for anesthesia." The policy lacked defined length of time the pre-anesthesia evaluation assessment may be completed prior to surgery.

B. Review of Patient 13's medical record (10/18/2023 at 1:01 PM) revealed the patient presented to the CAH on 4/5/2023 at 08:06 AM for an Esophagogastroduodenoscopy (EGD) (A scope tube is inserted through the mouth and down the patients throat to examine the lining of the esophagus, stomach and first part of the small intestine) under monitored anesthesia care (surgery start time 9:18 AM). Review of the Preanesthesia Evaluation electronically signed on 4/4/2023 at 10:16 AM by CRNA-F revealed a completed physical exam done the morning before the planned procedure. Interview (10/23/2023 at 8:25AM) with CRNA-F stated the Preanesthesia Evaluation [that included the physical exam] was done by "chart check" the day before the planned procedure "for time purposes." Review of the entire medical record lacked evidence of the patient's condition documented by CRNA-F prior to the procedure on 4/5/2023.

-Review of Patient 17's medical record (10/19/2023 at 12:10 PM) revealed the patient presented to the CAH on 9/26/2023 at 6:03 AM for a diagnostic Hysteroscopy and Dilation and Curettage (D&C) (a scope/tube with a camera is inserted in the vaginal region where the cervix is opened and used to view the uterus and remove tissue) under monitored anesthesia care (surgery start time 7:14 AM). Review of the Preanesthesia Evaluation electronically signed on 9/25/2023 at 11:18 AM by CRNA-F revealed a completed physical exam done the morning before the planned procedure. Interview (10/23/2023 at 8:25AM) with CRNA-F stated the Preanesthesia Evaluation [that included the physical exam] was done by "chart check" the day before the planned procedure "for time purposes." Review of the entire medical record lacked evidence of the patient's condition documented by CRNA-F prior to surgery on 9/26/2023.

-Review of Patient 19's medical record (10/19/2023 at 10:50 AM) revealed the patient presented to the CAH on 10/4/2023 at 6:05 AM for a Colonoscopy (scope/tube inserted into the rectum to view the colon) under monitored anesthesia care (surgery start time 7:14 AM). Review of the Preanesthesia Evaluation electronically signed on 10/3/2023 at 8:10 PM by CRNA-F revealed a completed physical exam done the night before the planned procedure. Interview (10/23/2023 at 8:25AM) with CRNA-F stated the Preanesthesia Evaluation [that included the physical exam] was done by "chart check" the day before the planned procedure "for time purposes." Review of the entire medical record lacked evidence of the patient's condition documented by CRNA-F prior to the procedure on 10/4/2023.

-Review of Patient 20's medical record (10/19/2023 at 10:03 AM) revealed the patient presented to the CAH on 10/17/2023 at 10:20 AM for a Left Total Knee Robotic Arthroplasty (removal of damaged tissue or joint in the knee and replaced with an artificial joint using a robotic arm assist for accuracy) under general anesthesia (surgery start time 1:18 PM). Review of the Preanesthesia Evaluation electronically signed on 10/16/2023 at 8:34 PM by CRNA-F revealed a completed physical exam done the night before the planned surgery. Interview (10/23/2023 at 8:25AM) with CRNA-F stated the Preanesthesia Evaluation [that included the physical exam] was done by "chart check" the day before the planned procedure "for time purposes." Review of the entire medical record lacked evidence of the patient's condition documented by CRNA-F prior to surgery on 10/17/2023.

C. An interview with CRNA-F (10/23/2023 at 8:25 AM) confirmed the above medical records Preanesthesia Evaluations which included a documented physical examination was done by "chart check" the day before the planned procedures "for time purposes." CRNA-F also stated, "I should have completed an addendum [physical assessment] the day of surgery."