HospitalInspections.org

Based on medical record review and interview the facility failed to complete a pre-anesthesia evaluation prior to surgery for 3 of 10 patients (1, 2, 4) reviewed.

Findings:

Pt. #1's MR review on 10/16/2014 at 11:45 a.m. revealed a surgery start time of 12:46 p.m. on 3/20/2014. Pre-anesthesia evaluation with physical exam is documented on 3/20/2014 at 2:58 p.m., after the start of surgery.

Pt. #2's MR review on 10/16/2014 at 1:25 p.m. revealed a surgery start time of 8:00 a.m. on 3/4/2014. Pre-anesthesia evaluation with physical exam is documented on 3/4/2014 at 8:18 a.m., after the start of surgery.

Pt. #4's MR review on 10/16/2014 at 1:32 p.m. revealed a surgery start time of 12:30 p.m. on 6/5/2014. Pre-anesthesia evaluation with physical exam is documented on 6/5/2014 at 1:19 p.m., after the start of surgery.

RN A confirmed these finding during medical record review. RN A stated during an interview on 10/16/2014 at 2:30 p.m. that the facility did not have a policy specific to documentation requirements related to anesthesia.

Based on medical record review and interview, the facility failed to maintain accurate operative records for 1 of 10 patients (#1) reviewed.

Findings:

Pt. #1 incurred injuries related to anesthesia emergence on 3/20/2014. Review of Pt. #1's MR on 10/16/2014 at 11:45 a.m. failed to include detail regarding any type of complication or adverse emergence from anesthesia.

During a phone interview with Res F on 10/16/2014 at 2:15 p.m., Res F stated that Res F was in the operating room during Pt. #1's surgery and was present as Pt. #1 "woke up" from anesthesia. Per Res F, Pt. #1 was "very combative" and "agitated" as Pt. #1 woke up from anesthesia. Res F stated that Pt. #1 attempted to "kick off" the table resulting in broken safety straps (used to restrain patients during surgery) and Res F lifted Pt. #1's leg back on to the table. Pt. #1 was the "most combative" patient that Res F had seen waking up from anesthesia. When asked about whether it is expected to document patients that are unusually combative upon waking from anesthesia, Res F stated "I don't know."

Review of operative notes failed to include Pt. #1's status upon waking from anesthesia. MD G dictated the final operative notes, MD G was not in the OR at the time of Pt. #1 waking from anesthesia per interview with Res F. Pt. #1's post-anesthesia documentation, written by Res D, states Pt. #1 had an "uneventful anesthesia course."

Res D stated during a phone interview on 10/16/2014 at 3:48 p.m. that Pt. #1's anesthesia course was standard, that there was nothing unusual about the Pt. #1's emergence from anesthesia and that Pt. #1 "definitely wasn't combative."

Based on an interview with MD C on 10/16/2014 at 11:15 a.m., MD C stated that the complications incurred by Pt. #1 are not uncommon. The complications suffered by Pt. #1 are routinely tracked as part of anesthesia quality assurance measures. MD C stated that documentation "could have been better" regarding Pt. #1's anesthesia course.

RN I stated during an interview on 10/16/2014 at 11:15 a.m. that it is "difficult to document combative emergence" in the OR due to limitations within the electronic health record.

During a phone interview with Res D on 10/16/2014 at 3:48 p.m., Res D stated that Res D administered 50 mcg of fentanyl to Pt. #1 prior to Pt. #1 moving from the pre-operative holding room into the OR. Review of Pt. #1's MR revealed that Pt. #1 received 75 mcg of fentanyl at 12:17 p.m., after the anesthesia start time of 12:11 p.m.

During an interview with MD C on 10/16/2014 at 3:30 p.m., MD C stated that pre-operative medications are documented on the intra-operative record as there is no other place within the electronic health record to document medications given pre-operatively. Per MD C, the facility does not have any policies that are specific to medication administration in the anesthesia department.

Facility policy "Medication Documentation" #C01.069 dated 6/25/2014, reviewed 10/16/2014 at 4:00 p.m., states in part "Documentation will be completed at the time of medication administration..."