HospitalInspections.org

Based on interview, clinical record review and review of facility policy, it was determined the facility failed to ensure the Surgeon documented a preoperative visit to a patient to indicate any changes, if any, on the patient's history and physical (H&P) and/or any changes in the patient's physical condition for one (1) of ten (10) sampled patients (Patient #1).

The findings include:

Review of facility policy, "Preoperative Requirements for Surgery or Other High Risk Procedures," policy A10-0609-29, effective date 03/29/12, revealed an H&P performed within thirty (30) days prior to the procedure could be used provided an interval note was recorded within twenty-four (24) hours of the procedure and included additions to the H&P and any changes in the physical findings.

Review of Patient #1's clinical record revealed he/she was admitted on 09/26/13, to have surgery that day to treat a failed fixation of compression hip screw in the right hip. Further review of the record revealed the H&P was done on 09/23/13; however, there was no documentation in the record that the Surgeon had seen Patient #1 preoperatively to document whether there were any changes to the H&P or physical findings for Patient #1.

Interview, on 10/25/13 at 4:30 PM, with the Manager of Performance Improvement,revealed no documentation could be found of the Surgeon's visit to Patient #1 preoperatively to indicate any changes in the H&P or the patient's condition. The interview further revealed per facility policy the Surgeon was required to make the preoperative visit, and there should be documentation of this.