HospitalInspections.org

Based on medical record review, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 6 of 6 surgical records (Patients 18, 19, 20, 21, 22 and 23) reviewed. This failed practice had the potential to affect all surgery patients of the CAH. Total surgical procedures performed in fiscal year 2018 was 686.

Findings are:

A. Review of Patient 18's medical record (8/21/19 at 11:15 AM) revealed the patient had a laparoscopic appendectomy (removal of the appendix through several small incisions, rather than through one large incision) on 2/6/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (12:09 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 19's medical record (8/21/19 at 11:25 AM) revealed the patient had an extracorporeal shock wave lithotripsy (administration of a series of shock waves by a machine focused by x-ray onto a kidney stone breaking it into small fragments) on 3/20/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (2:34 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 20's medical record (8/21/19 at 11:35 AM) revealed the patient had a colonoscopy (the inside of the large intestine; colon and rectum are examined) on 4/1/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (7:58 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 21's medical record (8/21/19 at 11:45 AM) revealed the patient had a laparoscopic inguinal hernia repair (to fix tears in abdominal muscle using small incisions, telescopes and a mesh patch) and vasectomy (sterilization procedure) on 5/6/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (10:39 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 22's medical record (8/21/19 at 11:50 AM) revealed the patient had a right cataract extraction with intraocular lens implantation (remove the lens of the eye and replace it with an artificial lens) on 6/5/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (6:58 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 23's medical record (8/21/19 at 12:00 PM) revealed the patient had a bilateral laparoscopic salpingectomy (removal of both fallopian tubes) on 7/23/19. The physician signed the progress note titled "Surgical Risk Evaluation" without evidence of the documented time of examination to ensure the examination occurred immediately before surgery (7:47 AM) to evaluate the risk of the procedure to be performed.

B. Review of policy and procedure titled Surgical Risk Evaluation (Revised date 11/10/15) revealed "A qualified practitioner must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed."

C. Interview with the DON (Director of Nursing) (8/22/19 at 9:40 AM) confirmed the above medical records lacked evidence of the documented time on the patient examinations to ensure the examinations occurred immediately before surgery to evaluate the risk of the procedure to be performed.