HospitalInspections.org

Based on document review and interviews, the facility failed to ensure that a properly executed informed surgical consent was present in the medical record before initiating surgical treatment for 3 of 10 medical records reviewed (Patient ID#s 4, 5 and 10).
Findings include:

Review of facility policy titled "Informed Consent," showed the following:
POLICY: The primary purpose of the informed consent process is to ensure that the patient, or the patient's representative, is provided the information necessary to enable him/her to evaluate a proposed procedure before agreeing to the procedure ...
Informed consent is a person's agreement to allow something to happen, made with full knowledge of the risks involved and the alternatives ...
A complete informed consent process includes a discussion of the following elements ...
" potential benefits, risks, or side effects, including potential problems that might occur during recuperation.

Review of medical record for patient (ID#4) for date of service 2/2/2025 showed the following:
Disclosure and Consent for Right Lunate Nonunion Reconstruction; Right Free Medial Femoral Trochlear Bone Flap; Right (BACKUP) Prosthetic Lunate Implant; Right (BACKUP) Tenoarthroplasty for Late Phase KIENBOCK'S
Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} None were listed or attached.

Review of medical record for patient (ID#5) for date of service 2/9/2025 showed the following:
Disclosure and Consent for: Right Scaphoid Nonunion Fixation and Grafting; Right Free Medial Femoral Condyle Bone Flap.
Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} None were listed or attached.

Review of medical record for patient (ID#10) for date of service 3/11/2025 showed the following:
Disclosure and Consent for: Right Lumbar Four to Lumbar Five, Lumbar Five to Sacral One Radiofrequency Ablation Rhizotomy.
Risks of this care/procedure(s) include but are not limited to {include List A risks here and additional risks if any} Not all appropriate Risk were included per the Texas Medical Disclosure Panel.

Interview with facility CNO (ID# 52) on 3/11/2025 at 2:00 PM acknowledged the above findings.

Based on record review and interview, the hospital failed to ensure nursing staff clarified physician medication orders that did not include the specific pain parameters for narcotic pain medication in the Post Anesthesia Care unit (PACU) in 2 of 10 patients (ID#s 4 and 9).

Findings include:

Review of facility policy titled" Medication Administration & MAR Documentation," showed the following:

PURPOSE: To establish standards for safe and timely administration and proper documentation on the medication administration record.
PROCEDURE:

D. 8. The nurse shall consult with the pharmacist at any time when question arise regarding medication administration.

Medical record for patient (ID#4) showed the following:

Medication order 12:55 on 2/2/2025: Dilaudid 0.5 mg IVPUSH Q5min PRN, MAX dose 4 mg, PRN Reason: Pain.

Medication order 12:55 on 2/2/2025: Fentanyl 100mcg/2 ML 25 mcg IV PUSH Q5min PRN, MAX dose 150 mcg, PRN Reason: Pain.

Patients (ID#4) received 0.5 mg Dilaudid at 12:59.


Medical record for patient (ID#9) showed the following:

Medication order 06:32 on 3/11/2025: Dilaudid 0.5 mg IVPUSH Q5min PRN, MAX dose 4 mg, PRN Reason: Pain.

Medication order 06:32 on 3/11/2025: Fentanyl 100mcg/2 ML 25 mcg IV PUSH Q5min PRN, MAX dose 150 mcg, PRN Reason: Pain.

Patients (ID#9) received 0.5 mg Dilaudid at 08:17.

Interview with facility CNO (ID# 52) on 3/11/25 at 11:00 AM stated that the order set should contain pain level parameters to know what medication to give or contain GIVE FIRST, SECOND, etc., instructions.

Based on record review and interview, the facility failed to ensure an updated examination of the patient, including any changes in the patient's condition, when the medical history and physical examination are completed within 30 days prior to surgery or a procedure requiring anesthesia services in 2 of 10 medical records (ID#s 4 and 5).

Findings include:

Record review of facility Medical Staff Rules and Regulations showed the following:
D. Medical Records
a. The attending Physician shall be responsible for the preparation of a complete, accurate, timely, legible and verifiable medical record for each patient ...
1) A complete medical record shall include:
vii. History and Physical Examination
b. .... If a complete history has been recorded and a physical examination performed within 30 days prior to the patient's admission to the hospital by a member of the medical staff, a reasonable, durable, legible copy of this report may be used in the patient's hospital medical record in lieu of the admission history and report of the physical examination, provided this report was recorded by a member of the medical staff and has appropriate update of the patient's condition. In such instances, an interval admission note that includes all additions to the history and any subsequent changes in the physical findings must always be recorded within 24 hours after admission, however, must be complete prior to any invasive operative procedure or any procedure which includes anesthesia.

Medical record for patient (ID#4) date of service 2/2/2025 showed the following:
History and Physical performed at office visit 1/7/2025, Surgeons Comment: Patient confirms no interval changes to medical status signed by physician staff (ID# 60) on 2/2/2025 at 08:16 AM. This document was faxed and scanned into the medical record 1/31/2025 (prior to date of surgery). Procedure start time on 2/2/2025 was 08:57 AM and surgery stop time was 12:20 PM.

Medical record review for patient (ID# 5) date of service 2/9/2025 showed the following:
History and Physical performed at office visit 2/5/2025, Surgeons Comment: Patient confirms no interval changes to medical status signed by physician staff (ID# 60) on 2/9/2025 at 10:03 AM. This document was faxed and scanned into the medical record 2/7/2025 (prior to date of surgery). Procedure start time on 2/9/2025 was 08:45 AM and surgery stop time was 11:46 PM.


Interview with facility CNO (ID# 52) on 3/11/2025 at 2:00 PM acknowledged the above findings.