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The Quality Assessment and Performance Improvement (QAPI) Program Condition of Participation was found out of compliance

Findings included:

The Hospital failed for 2 of 11 sampled patients (Patient #1 & #11) to ensure that QAPI activities thoroughly analyzed Patient #1's adverse patient event and death after surgery, implemented preventative actions by the time of the Survey, and included re-educating relevant staff throughout the Hospital after Patient #1's cardiac respiratory arrest, transfer to another hospital and death at the other hospital.

Refer to TAG: A-0286

The Hospital failed for 2 of 11 sampled patients (Patient #1 & #11) to ensure that the Hospital Executives were responsible and accountable for ensuring a thorough Hospital Internal Investigation, corrective actions were implemented, corrective actions were monitored for compliance and implementation and shared learnings throughout the Hospital as indicated.

Refer to TAG: A-0309

Based on records reviewed and interviews the Hospital failed for 2 of 11 sampled patients (Patients #1 & #11) to ensure Quality Performance Improvement (QAPI) activities thoroughly analyzed Patient #1's adverse patient event and death after surgery, implemented preventative actions by the time of the Survey, and included re-educating relevant staff throughout the Hospital after Patient #1's cardiac respiratory arrest, transfer to another hospital and death at the other hospital.

Findings included.

The following regarding Patient #1:

The Operative Note, dated at 4:37 P.M. on 2/15/18, indicated Patient #1 required general anesthesia due to a medical history that included Down syndrome (a chromosomal abnormality), developmental delay and that Patient #1 was non-verbal. The Operative Note indicated the Hospital transferred Patient #1 from the Operating Room, after removal of 12 of Patient #1's teeth, to the Post-Anesthesia Care Unit (PACU) in stable condition.

The Anesthesia Postoperative Record, dated 7:01 P.M. on 2/17/18, indicated Patient #1 suffered a cardiac arrest in the PACU and the Hospital transferred Patient #1 to a major medical center. The Anesthesia Postoperative Record indicated anoxic (lack of oxygen) brain injury. The Anesthesia Postoperative record indicated Patient #1 died from anoxic brain injury.

The Hospital Internal Investigation failed to thoroughly analyze and implement immediate corrective actions after Patient #1's cardiac respiratory arrest on 2/15/18.

The Document titled Action Plan Timeline, (undated), indicated the following 10 topics as discussed.

1.) The Action Plan Timeline, indicated the Anesthesia Provider (Anesthesiologist or Certified Registered Anesthetist) will remain with the patient until, oxygen was provided for all pediatric patients, to ensure oxygen monitoring, and will remain with the patient until the first set of vital signs was completed.

The Surveyor interviewed the Quality Medical Director at 10:00 A.M. on 3/15/18. The Quality Medical Director said that the Hospital did not implement corrective actions discussed and identified in response to Patient #1's cardiac respiratory arrest, adverse patient event (as of 3/15/18, the date of the Survey).

2.) The Action Plan Timeline indicated patients will be placed in a recovery position (on the abdomen).

The Quality Medical Director said that the Hospital did not implement this corrective action.

3.) The Action Plan Timeline indicated the Hospital will conduct Pediatric Code Blues (mock pediatric emergencies).

The Surveyor interviewed Registered Nurse (RN #1) at 11:30 A.M. on 3/15/18, the Anesthesia Chief at 2:00 P.M. on 3/15/18, RN #2 at 11:00 A.M. on 3/16/18, the Certified Registered Nurse Anesthetist (CRNA) at 2:10 P.M. on 3/16/18 and the PACU Nurse Manager at 8:05 A.M. on 3/19/18. RN's #1 & #2, the Anesthesia Chief, CRNA and PACU Nurse Manager said the Hospital did not implement pediatric mock codes.

The Surveyor interviewed RN #2 at 11:00 A.M. on 3/16/18. RN #2 said there were minutes that no one was running (taking the lead and organizing) the Patient #2's code (emergency) response team. RN #2 said Patient #1 needed an intravenous needle and she recommended an intraosseous (IO, needle into the bone to administer emergency medications and fluid) line and no one (emergency response team staff) knew how to place an intraosseous needle and that RN #1 said the Hospital did not have an intraosseous needle. RN #2 said that the Pediatric Emergency Cart stocked intraosseous needles.

The Hospital failed to conduct a thorough Hospital Internal Investigation and failed to identify if the Hospital had more than one Code Blue policy to analyze the policies for discrepancies and opportunities for improvement.

The Surveyor interviewed Hospitalist (Physician) #1 at 3:00 P.M. on 3/15/18. Hospitalist #1 said she was the chair (leader) of the Resuscitation Committee and the Resuscitation Committee reviewed all Code Blues. Hospitalist #1 said that the Resuscitation Committee had not reviewed Patient #1's Code Blue because the Resuscitation Committee meets quarterly. Hospitalist #1 said she wrote the Hospital Code Policy and that she did not think the Hospital Policy covered the PACU, and was not aware that the Surgical Services had a Code Policy.

4.) The Action Plan Timeline indicated the additional dose of Fentanyl (powerful narcotic), administered to Patient #1 by the CRNA, to calm Patient #1 for Emergence Delirium (emergence from general anesthesia accompanied by agitation).

The Hospital failed to conduct a thorough Hospital Internal Investigation and failed to analyze, discover, implement corrective actions regarding the documentation of Fentanyl by the CRNA as administered in the PACU and not in the Operating Room as indicated in the Anesthesia Intraoperative Record.

The Anesthesia Intraoperative Record indicated Patient #1 received Fentanyl, at 8:34 A.M. and 9:45 P.M. on 2/15/18, while in the Operating Room.

Department of Anesthesia Meeting Minutes, dated 2/27/18, and Department of Pediatrics Meeting Minutes, dated 2/27/18, indicated discussions regarding Patient #1's adverse event. The Meeting Minutes indicated no documentation for immediate corrective actions.

The Surveyor interviewed the Vice President for Quality and Patient Safety at 2:00 P.M. on 3/16/18. The Vice President for Quality and Patient Safety said the Certified Registered Nurse Anesthetist (CRNA) did not administer Patient #1 Fentanyl at 9:45 A.M. in the Operating Room as indicated in the Anesthesia Intraoperative Record and that the CRNA administered the Fentanyl at either 9:38 A.M. or 9:39 A.M. in the Post Anesthesia Care Unit.

The CRNA said that he documented the Fentanyl in the Anesthesia Intraoperative Record because he did not have access to the PACU record.

5.) The Action Plan Timeline indicated Hand-off (report form the Operating Room to the PACU staff) will include patient airways (breathing) risks.

The Hospital failed to conduct a thorough Hospital Internal Investigation and failed to analyze if the handoff of Anesthesia Care from one Anesthesiologist to another Anesthesiologist during Patient #1's dental surgery had a relationship to Patient #1's adverse event.

The Anesthesia Intraoperative Record indicated at 7:31 to 8:55 A.M. on 2/15/18, a Primary Anesthesiologist provided Patient #1 anesthesia care and at 8:55 A.M. to 10:06 A.M. on 2/15/18, a Secondary Anesthesiologist provided Patient #1 anesthesia care. The Anesthesia Intraoperative Record indicated no indication of documentation of handoff at 8:55 A.M. on 2/15/18.

The Quality Medical Director said that an Anesthesiologist started the case and another Anesthesiologist ended the case.

The Surveyor interviewed the Anesthesia Chief at 2:00 P.M. on 3/15/18. The Anesthesia Chief said the Primary Anesthesiologist handed off the Anesthesia care of Patient #1 to a Secondary Anesthesiologist, did not know why and that this was not optimal with a Pediatric case.

Department of Anesthesia Meeting Minutes and Department of Pediatrics Meeting Minutes indicated discussions regarding Patient #1's adverse event, however the Meeting Minutes indicated no documentation for immediate corrective actions.

6.) The Action Plan Timeline indicated that the PACU staff will adjust lighting for effective monitoring (to see the patient).

The Quality Medical Director said that the Hospital did not implement corrective actions.

7.) The Action Plan Timeline indicated criteria for surgery cancellation was discussed.

The Quality Medical Director said that the Hospital did not implement corrective actions.

8.) The Action Plan Timeline indicated Pediatric Advanced Life Support (PALS) requirement for Anesthesia Providers was discussed.

9.) The Action Plan Timeline indicated Pediatric transfer to higher level of care was discussed.

The Surveyor interviewed the Pediatric Hospitalist Director at 1:00 P.M. on 3/16/18. The Pediatric Hospitalist Director said that the Pediatric transfer process to Hospital B for a higher level of pediatric care was not a smooth process and corrective actions were not implemented.

10.) The Action Plan Timeline indicated Sleep Apnea evaluation in pediatric patients was discussed.

The Quality Medical Director said that the Hospital did not implement corrective actions.

The following regarding patient weights:

The Hospital failed to conduct a thorough Hospital Internal Investigation and failed to identify that Hospital staff weighed Patient #1 in pounds as stated (weight that was reported and not an actual weight) and a discrepancy in the documentation of Patient #1's weight in pounds as stated in the electronic medical record,

The Hospital Policy titled Weighing Patient, dated 10/2016, indicated stated weights were not acceptable and Hospital staff weighed and recorded in the electronic medical record pediatric weights in kilograms. The American Academy recognized, in 3/2017, weighing of all patients in kilograms.

The Hospital policy titled Department of Pharmacy Services Prevention of Pediatric Errors in the In-Patient Setting, dated 6/22/16, indicated the standard weight throughout the institution (Hospital) was a weight in kilograms for pediatric patients. The policy titled indicated the policy was for in-patients and the policy content indicated the policy was for pediatric weights throughout the Hospital.

The Anesthesia Preoperative Record indicated Patient #1's weight as Stated (not an actual weight) at 46 pounds. The Nursing Preoperative Record, dated as 7:38 A.M. on 2/15/18, indicated Patient #1 weighed as Stated at 43 pounds. The Anesthesia Preoperative Record and the Nursing Preoperative Record indicated no indication of an actual weight in kilograms in accordance with recognized pediatric care, the American Academy of Pediatrics or in accordance with Hospital policy.

The CRNA said that Patient #1's weight was a stated weight and assumed stated by Patient #1's family and the weight was not an actual weight.

The Hospital Internal Investigation indicated no documentation of the discrepancies in the Hospital policy titled Department of Pharmacy Services Prevention of Pediatric Errors in the In-Patient Setting, dated 6/22/16.

The following regarding PACU admission times:

The Hospital failed to conduct a thorough Hospital Internal Investigation and failed to identify the discrepancy in PACU admission times.

The Anesthesia Intraoperative Record indicated Anesthesia, at 9:52 A.M., extubated (removed the breathing tube) and at 9:53 A.M., the oxygen saturation reading was 90. The Anesthesia Intraoperative Record indicated Anesthesia, at 10:06 A.M., transferred Patient #1 to the PACU (discrepancy in PACU admission time with the Nursing Post Anesthesia Care Unit Record).

The following regarding Patient #2:

The Document titled Emergency Department (ED) Pediatric Event, dated 3/7/18, indicated the ED did not administer an antibiotic to a Pediatric patient (Patient #2)

The Surveyor interviewed the ED Nurse Director at 10:00 A.M. on 3/16/18. The ED Nurse Director said the ED Nurse documented the antibiotic as administered in Patient #2's electronic medical record prior to administering the antibiotic, the ED RN did not administer the antibiotic, and that this process was not consistent with Hospital policy. The ED Nurse Director said the Hospital did not implement immediate corrections (by the time of the Survey, 9 days after the event).

The Hospital policy titled Medication Administration, dated 10/16/13, indicated scheduled doses of medications were administered within one hour before or after the time of the scheduled dose. The policy indicated that the nurse documented on the medication administration record the date and time the nurse hung an intravenous medication. The policy indicated that if the medication was not administered the medication was returned to the medication drawer.

Based on records reviewed and interviews the Hospital failed for 1 of 11 sampled patients (Patient #1) to ensure Hospital Executives were responsible and accountable for a thorough Hospital Internal Investigation, implementation of corrective actions, monitoring corrective actions for compliance and re-eduction of relevant staff throughout the Hospital after Patient #1's cardiac respiratory arrest.

Findings included:

The Document titled Performance Improvement Plan, dated 2/2016, indicated the Board of Directors was responsible for the development and implementation of an effective Quality Program. The Performance Improvement Plan indicated the performance improvement process was completed in a timely manner to identify problems to be eliminated or minimized early. The Performance Improvement Plan indicated the Performance Improvement Committee was responsible for the implementation of corrective action plans.

The document titled Chief Nursing Officer, dated 6/2009, indicated responsibilities of the Chief Nursing Officer included collaboration with senior leadership and medical leadership to develop and implement programs to measure, evaluate and improve the quality of patient care.

The Surveyor interviewed the Quality Medical Director at 10:00 A.M. on 3/15/18. The Quality Director said that the Hospital did not implement immediate or corrective actions in response to Patient #1's cardiac respiratory arrest.

The Surveyor interviewed the Vice President for Patient Care Services Chief Nursing Officer at 3:50 P.M. on 3/15/18. The Vice President said that the Hospital knew on 2/15/18 (the day of Patient #1's adverse event) that the Hospital did not monitor Patient #1 (adequately evaluate Patient #1's respiratory rate and heart rate).

The Hospital provided no documentation to indicate immediate corrective actions were implemented.

The Condition of Participation for Nursing Services was out of compliance

Findings included:

The Hospital failed for 1 of 11 sampled patients (Patients #1) to ensure Nursing Services was responsible for the operation of the service, including determining the types (competencies) of nursing personnel necessary to provide nursing care to pediatric patients with special needs in the Post Anesthesia Care Unit (PACU).

Refer to TAG: A-0386

The Hospital failed for 1 of 11 sampled patients (Patient #1) Nursing Services ensured that Registered Nurse #1 evaluated (monitored) Patient #1 post-anesthesia special pediatric care needs, Patient #1's response to interventions in accordance with accepted standards of pediatric nursing practice and Hospital policy.

Refer to TAG: A-0395

The Hospital failed for 1 of 11 sampled patients (Patient #1) Nursing Services ensured that Perioperative Services Nursing Staff developed Patient #1's post-anesthesia nursing care plan to include Patient #1's special pediatric nursing care needs.

Refer to TAG: A-0396

The Hospital failed to ensure for 1 of 11 sampled patients (Patient #1) that Nursing Services was responsible for the operation of the service, including determining the types (competencies) of nursing personnel necessary to provide nursing care to pediatric patients with special needs in the Post Anesthesia Care Unit (PACU).

Findings included:

The Nursing Pre-admission Record, dated at 9:59 A.M. on 2/08/18, indicated Patient #1 with an evaluation of developmental delay and a pre-operative diagnosis of acute stress reaction. The Nursing Pre-admission Record indicated no indication of a care plan individualized for the needs of Patient #1 as a pediatric patient with developmental delay and acute stress reaction.

The document titled Chief Nursing Officer, dated 6/2009, indicated responsibilities of the Chief Nursing Officer included, development and implementation of a plan to meet the learning needs of patient care staff essential to ensure the appropriate level of care.

Surgical Services Post Anesthesia Care Unit Standards of Care, dated 1/2016, indicated PACU nurses were specially trained and received continuing education relevant to Post Anesthesia Care, and the Hospital documented in their personnel record.

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Orientation of New PACU Personnel, dated 10/2016, indicated all new personnel employed in the PACU were oriented to safe and competent practice. The policy indicated no indication of orientation to competencies (types, in accordance with this Standard) of nursing personnel necessary to provide nursing care to pediatric patients with special needs in the PACU.

The Document titled Surgical Services, PACU, Annual Skills Week, dated 2017, indicated competency requirements for the Emotional Response of Hospitalization of Children in a poster presentation with a post-test and Pediatric Assessment and Developmentally Appropriate Care of the Pediatric Patient as a module (reading-learning) competency. The Surgical Services, PACU, Annual Skills Week Document indicated no documentation of competency requirements specific for pediatric PACU care needs, specialized developmentally delayed pediatric PACU care needs, consistent with accepted standards of perioperative pediatric nursing to individualize a nursing plan of care for pediatric patients' response to anesthesia and the experience of surgery.

The Document titled PACU RN Intra-operative Anesthesia Observation, undated, and the Document titled Intra-operative Anesthesia Observation Worksheet, undated, indicated no documentation of a competency requirement regarding care of the pediatric patient or competency requirements for development of a nursing care plan according to the special needs of pediatric patients post anesthesia and surgery.

The Document titled General Orientation for the PACU RN, undated, indicated a competency requirement for the RN to use age appropriate guidelines when teaching children. The General Orientation for the PACU RN Document indicated no other competency requirements for the specialized needs of pediatric patients.

The Surveyor interviewed the Certified Registered Nurse Anesthetist (CRNA) at 2:10 P.M. on 3/16/18. The CRNA said that Patient #1 had Emergence Delirium (emergence from general anesthesia accompanied by agitation).

The Documents titled Surgical Services, PACU, Annual Skills Week, PACU Registered Nurse (RN) Intra-operative Anesthesia Observation, Intra-operative Anesthesia Observation Worksheet; General Orientation for the PACU RN indicated no documentation of a competency evaluation requirement for Emergency Delirium.

The Surveyor interviewed RN #2 at 11:00 A.M. on 3/16/18. RN #2 said Patient #1 needed an intravenous (IO, needle into the bone to administer emergency medications and fluid) needle and she recommended an intraosseous needle procedure. RN #2 said RN #1 said the Hospital did not have an intraosseous needle. RN #2 said that the Pediatric Emergency Cart stocked intraosseous needles.

The Surveyor interviewed the PACU Nurse Manager at 8:05 A.M. on 3/19/18. The PACU Nurse manager said the Hospital did not offer PACU personnel pediatric mock codes and did not offer pediatric specific education or pediatric specific modules (learning materials).

The Hospital failed for 1 of 11 sampled patients (Patient #1) to ensure that Nursing Services ensured Registered Nurse (RN) #1 evaluated and monitored Patient #1 post-anesthesia special pediatric care needs, Patient #1's response to post-anesthesia interventions, before Patient #1's cardiac and respiratory arrest, in accordance with accepted standards of pediatric nursing practice and Hospital policy.

Findings included:

The document titled Chief Nursing Officer, dated 6/2009, indicated responsibilities of the Chief Nursing Officer included, development and implementation of a plan to maintain the standards of nursing practice.

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Admission to PACU, dated 2/2018, indicated the initial nursing evaluation of the patient included vital signs for pediatric patients with a minimum of pulse oximetry and respiratory rate, color and condition (monitoring the patient's condition).

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Care of the Pediatric Patient in the PACU, dated January 2016, indicated pediatric patients deserve special individualized care and a return to a familiar environment and their families as soon as possible. The policy indicated pediatric patients emerge from anesthesia differently than adults and that it is essential that the PACU RN meet their emotional as well as physical needs. The policy indicated parents were very comforting to a child. Their presence can greatly reduce anxiety and stress associated with the recovery period. The PACU Personnel and Pediatric Intervention Team encourages parental visitation in the PACU especially for children with special needs or those who may not be comforted by the PACU Personnel after repeated attempts.

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Standards of Care, dated 1/2016, indicated PACU nurses were specially trained and received continuing education relevant to Post Anesthesia Care, and the Hospital documented in their personnel record. The policy indicated the initial physical assessment upon arrival to the PACU included vital signs and oxygen therapy and oxygen saturation level. The policy indicated the Hospital monitored all patients in the PACU for oxygen saturation. The policy indicated that the Department of Anesthesia was responsible for patient care in the PACU.

The Surveyor interviewed RN #2 at 11:00 A.M. on 3/16/18. RN #2 said Patient #1 arrived into the PACU agitated, she requested to RN #1 (RN #1 was RN #2's preceptor, teacher as RN #2 was a new nurse employee to the PACU) that Patient #1 parents come to the bed-side and RN #2 said RN #1 said no. RN #2 said RN #1 said Patient #1 needs to settle down. RN #2 said, then the Certified Registered Nurse Anesthetist (CRNA) administered Patient #1 Fentanyl (a powerful narcotic) instead. RN #2 said she did not know why they (RN #1 and the CRNA) gave the Fentanyl before Patient #1's parents were allowed into the PACU. RN #2 said PACU personnel did not evaluate Patient #1's breath sounds, and Patient #1 was not administered supplemental oxygen. RN #2 said they (RN #1 & RN #2) could not obtain a good oxygenation reading. Patient #1 was not on a cardiac monitor. RN #2 said Anesthesia (the CRNA) did not stay with Patient #1 until Patient #1 was on the oxygen saturation monitor. RN #2 said that if the readings were accurate we should be doing something. RN #2 said Patient #1 toe was blue, turned Patient #1 over and Patient #1 was blue, she felt no pulse and started chest compressions.

The Anesthesia Intraoperative Record, dated 2/15/18, indicated Patient #1's oxygen saturation was 90 at 9:53 A.M. The Nursing Post Anesthesia Care unit Record, dated 2/15/18 at 9:58 A.M., indicated Patient #1 had a heartbeat of 64 beats per minute (very low) with an oxygen saturation level of 80 (low); at 10:06 A.M. Patient #1 was agitated and staff unable to evaluate lung sounds; at 10:08 A.M. Patient #1 was agitated and Hospital Staff unable to obtain vital signs; at 10:10 A.M. Patient #1 appears sleeping; at 10:15 A.M. Patient #1's color was pink; at 10:21 A.M. Patient #1 had shallow and diminished lung sounds; at 10:24 A.M. Patient #1 has a heartbeat of 240 beats per minute (very fast) with an oxygen saturation level of 79. The Anesthesia Intraoperative Record indicated no documentation that PACU personnel notified a Provider (Doctor) to examine Patient #1 at 10:21 A.M. as Patient #1 had shallow and diminished lung sounds.

The Resuscitation Flow Sheet, dated 2/15/18 at 10:30 A.M., indicated resuscitation started. The Nursing Post Anesthesia Care Unit Record indicated no indication of a nursing note to summarize the events between 10:15 A.M. when a PACU RN evaluated Patient #1 with a pink color and the start of the resuscitation at 10:30 A.M. on 2/15/18.

The Hospital failed to ensure for one (Patient #1) of 11 patients sampled that Nursing Services ensured that Perioperative Services Nursing Staff developed Patient #1's post-anesthesia nursing care plan to include Patient #1's special pediatric nursing care needs.

Findings included:

The Hospital policy titled Assessment and Reassessment of Patients, dated 7/31/16, indicated the patient plan of care was developed utilizing information collected through assessment and screening processes to meet the patient care needs.

The Nursing Pre-admission Record, dated at 9:59 A.M. on 2/08/18, indicated Patient #1 with an evaluation of developmental delay and a preoperative diagnosis of acute stress reaction. The Nursing Pre-admission Record indicated no indication of a care plan individualized for the needs of Patient #1 as a pediatric patient with developmental delay and acute stress reaction.

The Nursing Preoperative Record, dated as 7:38 A.M. on 2/15/18 indicated no documentation that Patient #1 was non-verbal; however, the Operative Note, dated at 4:37 P.M. on 2/15/18, indicated Patient #1 was non-verbal. The Nursing Perioperative Record indicated the language as English and the Perioperative Record indicated no indication of how Patient #1 communicated.

The Nursing Preoperative Record indicated no documentation of a nursing plan of care, individualized for Patient #1 as a pediatric patient with developmental delay and non-verbal.

The Condition of Participation for Anesthesia Services was out of compliance.

Findings included:

Anesthesia Services failed to ensure for 1 of 11 sampled patients (Patient #1) that Anesthesia Services were delivered in a manner consistent with Patient #1's needs, delivered consistent with recognized standards for Anesthesia care and in accordance with Hospital policy.

Refer to TAG: A-1002

Anesthesia Services failed to ensure for 1 of 11 sampled patients (Patient #1) that Patient #1's post anesthesia evaluation for anesthesia recovery in the Post Anesthesia Care Unit (PACU) included respiratory function, respiratory rate, airway patency and oxygen saturation (monitored Patient #1's condition) and was completed in accordance with Hospital policy.

Refer to TAG: A-1005

Based on records reviewed and interviews Anesthesia Services failed to ensure for 1 of 11 sampled patients (Patient #1) that Anesthesia Services were delivered in a manner consistent with Patient #1's needs, delivered consistent with recognized standards for Anesthesia care and in accordance with Hospital policy.

Findings included:

The following regarding specialized care for pediatric patients:

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Care of the Pediatric Patient in the Post Anesthesia Care Unit (PACU), dated January 2016, indicated pediatric patients deserve special individualized care and a return to a familiar environment and their families as soon as possible. The policy indicated parents were very comforting to a child. Their presence can greatly reduce anxiety and stress associated with the recovery period. The PACU staff and Pediatric Intervention Team encourages parental visitation in the PACU especially for children with special needs or those who may not be comforted by the PACU staff after repeated attempts.

The Anesthesia Preoperative Record, dated at 7:30 A.M. on 2/15/18, indicated Patient #1 as a child with developmental delay and Down syndrome. The Anesthesia Preoperative Record indicated an anesthesia plan of care for an adult patient. The anesthesia plan of care indicated the anesthesiologist discussed with the patient risks and benefits. The anesthesia plan of care indicated no documentation of risk and benefit discussion with Patient #1's parents. The anesthesia plan of care indicated the Post Anesthesia Care Unit (PACU) or the Cardiac Care Unit (CCU) as a possibility for postoperative care. The anesthesia plan of care indicated no documentation of a possibility for a pediatric specific unit for postoperative care. The anesthesia plan of care indicated no documentation of a plan of care consistent with Patient #1's postoperative needs as a child with developmental delay or Emergence Delirium (emergence from general anesthesia accompanied by agitation).

The Hospital policy titled Department of Anesthesia and Perioperative Medicine Documentation of Anesthesia Care, dated 11/16/16, indicated Anesthesia Staff documented in the patient's medical record a post anesthesia evaluation of the patient's physiologic condition and presence or absence of anesthesia related complications or complaints and the patient's status (condition) at the time of transfer.

The Surveyor interviewed Registered Nurse (RN) #2 at 11:00 A.M. on 3/16/18. RN #2 said Patient #1 arrived into the PACU agitated, PACU personnel could not obtain breath sounds, could not administer supplemental oxygen, and could not obtain a clear oxygenation readings. RN #2 said Patient #1 was not on a cardiac monitor. RN #2 said Anesthesia did not stay with Patient #1 until Patient #1 was on an oxygen saturation monitor. RN #2 said that if the readings were accurate we should be doing something.

The Surveyor interviewed the Anesthesia Chief at 2:00 P.M. on 3/15/18. The Anesthesia Chief said the incidence of Emergence Delirium was higher in children.

The Surveyor interviewed the Certified Registered Nurse Anesthetist (CRNA) at 2:10 P.M. on 3/16/18. The CRNA said that Patient #1 had Emergence Delirium, was very agitated, screaming and unable to administer oxygen while in the Operating Room after extubation (breathing tube removal) and administered Fentanyl for the agitation. The CRNA said Emergence Delirium was not uncommon with children. The CRNA said that the post anesthesia plan of care was the same (for all patients) and included vigilance focused on the airway (breathing).

The following regarding Anesthesia Services failure to lead Patient #1's cardiopulmonary resuscitation (CPR, Code Blue) according to Hospital policy.

The Hospital policy titled Surgical Services Department of Surgical Services and Anesthesia Perioperative Services Emergencies Code Blue Response in the Perioperative Setting (PACU), dated 4/20/16, indicated an attending anesthesiologist was the Code Blue leader (organized the response team personnel responding to the emergency).

The Surveyor interviewed RN #1 at 11:30 A.M. on 3/15/18. RN #1 said roles (functions and responsibilities of the emergency team) were not delineated during the Code Blue.

The Surveyor interviewed RN #2 at 11:00 A.M. on 3/16/18. RN #2 said there were minutes that no one (of the emergency team personnel) was running (organizing) the code. RN #2 said Patient #1 needed an intravenous needle and she recommended an intraosseous (IO, needle into the bone to administer emergency medications and fluid) line, and no one knew how to place an intraosseous needle and RN #1 said the Hospital did not have an intraosseous needle. RN #2 said that the Pediatric Emergency Cart stocked intraosseous needles.

Based on records reviewed and interview Anesthesia Services failed to ensure for 1 of 11 sampled patients (Patient #1) that Patient #1's post anesthesia evaluation for anesthesia recovery in the Post Anesthesia Care Unit (PACU) included respiratory function, respiratory rate, airway patency and oxygen saturation (monitored Patient #1's condition) and was completed in accordance with Hospital policy.

Findings included:

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Admission to PACU, dated 2/2018, indicated medical supervision and coordination of patient care in the PACU was the responsibility of the Department of Anesthesiology (Anesthesia Services).

The Hospital policy titled Surgical Services Post Anesthesia Care Unit Safe Transfer of Patient Care, dated 7/2015, indicated that the Anesthesia Department was responsible for the safe transfer (hand-off) of care from the Anesthetist or Anesthesiologist to the PACU personnel.

Surgical Services Post Anesthesia Care Unit Standards of Care, dated 1/2016, indicated the initial physical assessment upon arrival to the PACU included vital signs and oxygen therapy and oxygen saturation level. The policy indicated the Hospital monitored all patients in the PACU for oxygen saturation.

The Hospital policy titled Assessment and Reassessment of Patients, dated 7/31/16, indicated the patient's status (condition) was evaluated (monitored) by an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) immediately upon arrival to the PACU.

The Anesthesia Intraoperative Record indicated Patient #1 received 62.5 mcg of Fentanyl (powerful narcotic), extubation (breathing tube removed) at 9 :52 A.M., oxygen saturation reading was 90 at 9:53 A.M. and at 10:06 A.M. transferred to the PACU.

The Nursing Post Anesthesia Care unit Record, dated 2/15/18 at 9:58 A.M., indicated Patient #1 had a heartbeat of 64 beats per minute (very low) with an oxygen saturation level of 80 (low), at 10:06 A.M. Patient #1 was agitated and staff unable to evaluate lung sounds, at 10:08 A.M. Patient #1 was agitated and Hospital Staff unable to obtain vital signs, at 10:10 A.M. Patient #1 appears sleeping, at 10:15 A.M. Patient #1's color was pink, at 10:21 A.M. Patient #1 has shallow and diminished lung sounds and at 10:24 A.M. Patient #1 has a heartbeat of 240 beats per minute (very fast) with an oxygen saturation level of 79. The Nursing Post Anesthesia Care Unit Record indicated no documentation to indicate PACU Personnel notified an Anesthesia Provider of Patient #1's shallow and diminished lung sounds evaluated at 10:21 A.M.

The Resuscitation Flow Sheet, dated 2/15/18, indicated at 10:30 A.M. resuscitation started.

The Surveyor interviewed Registered Nurse (RN #1) at 11:30 A.M. on 3/15/18. RN #1 said Anesthesia did not stay with Patient #1 until Patient #1 was monitored (evaluated and effective oxygen monitoring).

The Hospital provided no documentation to indicate that Anesthesia Services delivered Patient #1 appropriate physiologic monitoring (vital sign evaluation, heart rate, respiratory rate, oxygenation level) after surgery consistent with recognized standards of pediatric anesthesia care, in accordance with the American Academy of Pediatrics Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures, dated 2016, and in accordance with Hospital policy.