HospitalInspections.org

Based on interview, record review, policy review, and review of medical staff rules, the provider failed to ensure five of nine sampled surgery patients (14, 16, 17, 31, and 32) had documentation of a history and physical (H and P) examination performed by a medical professional prior to planned outpatient surgical procedures. Findings include:

1. Review of patient 17's 4/19/22 surgical chart revealed she had:
*A planned outpatient surgical procedure.
*An anesthesia start time documented at 9:58 a.m. on 4/19/22.
*An H and P completed by certified nurse practitioner (CNP) D at 10:08 a.m.
-The H and P was cosigned by medical doctor (MD) E on 4/20/22 at 1:42 p.m.

2. Review of patient 32's 5/3/22 surgical chart revealed she had:
*A planned outpatient surgical procedure.
*An anesthesia start time had been documented at 10:48 a.m. on 5/3/22.
*An H and P completed by CNP D on 5/3/22 at 11:11 a.m.
-The H and P was co-signed by MD E on 5/5/22 at 10:01 a.m.

3. Review of patient 16's 3/1/22 surgical chart revealed he had:
*A planned outpatient surgical procedure.
*An anesthesia start time had been documented at 8:35 a.m. on 3/1/22.
*An H and P completed by CNP D on 3/1/22 at 9:21 a.m.
-The H and P was cosigned by MD E on 3/1/22 at 2:43 p.m.

4. Review of patient 14's 8/2/22 surgical chart revealed he had:
*A planned outpatient surgical procedure.
*An anesthesia start time had been documented at 10:21 a.m. on 8/2/22.
*An H and P completed by CNP D on 8/2/22 at 11:35 a.m.
-The H and P had been cosigned by MD E on 8/3/22 at 2:38 p.m.

5. Review of patient 31's 3/15/22 surgical chart revealed he had:
*A planned outpatient surgical procedure.
*An anesthesia start time documented on 3/15/22 at 9:23 a.m.
*An H and P had been completed by MD E on 3/15/22 at 9:27 a.m.

Interview on 8/11/22 at 11:30 a.m. with chief nursing officer (CNO) B and quality and risk director C revealed:
*H and Ps were to be completed prior to the start of a procedure.
*They had been aware the documented times of the H and Ps were not always prior to the start of the procedures.
*The physician who completes the procedure, also completes the H and P the same day of the procedure.
*The physician and CNP sometimes documented the H and Ps after the procedure.

Further interview on 8/11/22 at 12:02 p.m. with CNO B revealed:
*The surveyor had inquired if patients 14, 16, 17, 31, and 32 had H and Ps completed at the clinic within the 30 days leading up to the procedure.
-She had been unable to find any other documentation of H and Ps completed for patients 14, 16, 17, 31, and 32.

Review of the providers July 2015 Medical Staff Rules and Regulations revealed, "...For patients undergoing non-emergent operative or invasive procedures, the H & P must be documented in the medical record prior to the surgical procedure..."

Review of the provider's September 2019 Procedural Sedation and Analgesia Sioux Falls, SF [Sioux Falls] Region ASCs [ambulatory surgical centers] and CAH [critical access hospital] policy revealed:
*Before a patient had a moderate or deep sedation procedure, they were to have:
-"Appropriate History and Physical (H and P) as required by the medical staff rules and regulations."