HospitalInspections.org

Based on the review of six medical records, policies/procedures of the operating room with the Assistant Nursing Director (employee #4) during the follow-up visit, it was determined that the facility failed to execute complete surgery informed consents that includes date, hour and signed by the physician for two out of six records reviewed (R.R #14 and #20).

Deficiencies Not Corrected

Findings include:

1. During the review of six medical records on 8/26/10 from 9:00 am till 10:00 am, the following was determined:

a. R.R #14 provided evidence that the surgical procedure consent form did not include the date, hour and signature of the physician when the consent was taken.

b. R.R #20 provided evidence that the surgical procedure consent form did not include the date and signature of the physician when the consent was taken.

Based on the review of six medical records to evaluate anesthesia services with the Assistant Nursing Director (employee #4) during the follow-up visit, it was determined that the facility failed to ensure that informed consent forms are properly executed for four out of six records reviewed (R.R #13, #14, #15 and #16).

Deficiencies Not Corrected.

Findings include:

1. During the review of six medical records on 8/26/10 from 9:00 am till 10:00 am, the following was determined:

a. R.R #13 provided evidence that the anesthesia consent form failed to have the hour, date and signature of the anesthetist when the consent was taken.

b. R.R #14 provided evidence that the anesthesia consent form lacks the date and hour when the consent was taken.

c. R.R #15 provided evidence that the anesthesia consent form did not provide space to write the hour that the consent was taken.

d. R.R #16 provided evidence that the anesthesia consent form failed to have the hour, date and signature of the anesthetist when the consent was taken.

Based on the review of the physician's on-call list, interview and the observational tour with the emergency nurse supervisor (employee #3) during the follow-up visit, it was determined that the facility failed to comply with EMTALA regulations related to on-call surgeons roster to cover the emergency room in the event that this specialty is needed.

Deficiencies Not Corrected.

Findings include:

1. No evidence was found on 8/26/10 at 9:30 am during the follow-up visit of an on-call surgeon roster to cover the Emergency Room in the event that this specialty is needed. The Medical Director (employee #2) stated during an interview on 8/26/10 at 10:30 am that there is a problem with this specialty for on-call services and it is being discussed with the Medical Staff to reach an agreement with these physicians so that they can comply with an on-call program for surgeons. He also stated that they have always stressed the importance of having a complete on call schedule for surgeons for the entire month, and even though some days are not covered all consultations are answered. The facility's administrator (employee #1) stated during an interview on 8/26/10 at 3:30 pm that they have an on-call list of surgeons for the months of July 2010 and August 2010, but it is not complete for every day of the month. She said that some days of the month are not covered by the schedule (eleven days for July and five days for August). She also stated that during faculty meetings they have stressed the importance of having a complete on call schedule for surgeons for every month but the medical faculty has been resistant to agree with this request.

2. No evidence was found of the first call, second call or the signature of the head of the department or the medical director as reviewed on 8/26/10 at 10:30 am.