HospitalInspections.org

Based on document review and interview, the facility failed to follow its Medical Staff Bylaws and its Quality Assurance and Improvement (QAPI) plan and ensure all patient records meeting surgery and anesthesia department review triggers were identified and reviewed for one occurrence (Patient #1).

Findings include:

1. Review of the Quality Assurance and Improvement (QAPI) Plan (approved 11-19) indicated the following: "The Board delegates the responsibility for implementing this QAPI Plan to the medical staff, the hospital's leadership team and the Quality Improvement Committee."

2. Review of the Medical Staff Bylaws (approved 1-15) indicated the following: "Article XII: Committees... 12-1-3 Quality and appropriateness of care/morbidity... (c)... establish and utilize objective criteria in the collection and assessment of information; and (d) document the findings from the monitoring, assessment, and problem-solving activities, and the action taken to resolve problems and improve patient care."

3. Review of the document Medical Staff Quality Measures Monitored by Quality Department (no review date) indicated the following: "(b) Surgery and Anesthesia Department Review Triggers... Patient transfer to another facility during perioperative period..."

4. Review of the medical record (MR) for Patient #1 indicated on 12-23-16 the surgical patient experienced respiratory failure during the immediate post-operative period and was transferred to another hospital for ongoing care.

5. On 4-7-21 at 1300 hours, the Vice President of Nursing A2 was requested to provide any QAPI or Medical Staff documentation indicating a surgery and anesthesia department review was performed for any of the MRs sampled to review and none was provided prior to exit.

6. On 4-7-21 at 1500 hours, the Safety, Compliance and Risk Manager A4 confirmed the facility lacked documentation indicating a surgery and anesthesia department review was conducted in 2017 for the indicated MR and confirmed no other documentation was available.

Based on document review and interview, the facility failed to ensure an informed consent was documented in the medical record for 1 of 10 surgical records reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Transfer of a Patient to Another Acute Care Facility (reviewed 12-15) indicated the following: "Patients requiring transfer should have the risks and benefits of transfer explained to him/her or his/her appointed guardian, representative, or next of kin prior to transfer. Patient consent to transfer should be obtained prior to transfer..."

2. Review of the MR for Patient #1 indicated the Orthopedic Surgeon MD13 discussed the need to transfer the post-operative patient to another hospital with the patient's spouse and family member FM31 and lacked documentation indicating written and/or verbal consent for the patient transfer was obtained from the patient or the patient's representative FM31.

3. On 4-6-21 at 1500 hours, the Vice President of Nursing A2 confirmed the MR for Patient #1 lacked the above.

Based on document review and interview, the facility failed to ensure a history and physical (H&P) examination was present in the medical record (MR) prior to surgery for 1 of 10 surgical records reviewed (Patient #10).

Findings include:

1. Review of the Medical Staff Rules and Regulations (approved 1-15) indicated the following: "A medical record shall be considered incomplete if it needs any of the following...b. History and Physical...[and]... A surgical patient's chart must include: Complete history and physical exam prior to surgery..."

2. Review of the MR for Patient #10 indicated the patient was admitted on 12-23-16 to the outpatient surgery unit for a left shoulder arthroscopy and rotator cuff repair procedure and lacked documentation indicating a H&P was present in the MR.

3. On 4-7-21 at 1538 hours, staff A5 confirmed the MR for Patient #10 lacked the above.

Based upon document review and interview, the facility failed to follow its policies and procedures and ensure that copies of medical records (MR) were sent with the transfer patient to the receiving facility for 1 of 10 MR reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Transfer of a Patient to Another Acute Care Facility (reviewed 12-15) indicated the following: "The following information should be sent with the patient and communicated with the receiving facility... Patient name...vital signs... medications administered... History and Physical... reason for transfer... nursing notes... all tests and procedures performed..."

2. Review of the MR for Patient #1 indicated the post-operative patient was transferred to another hospital for ongoing care and lacked documentation indicating the copies of the MR that were available at the time of transfer and sent with the patient to the receiving facility.

3. On 4-6-21 at 1500 hours, the Vice President of Nursing A2 confirmed the above.