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Based on Medical Staff Bylaws review, medical record review, and interview, the hospital failed to ensure an updated examination of the patient, including any changes in the patient's condition, was documented and in the medical record prior to the surgery when the medical history and physical examination (H&P) was completed within 30 days before admission or registration for one of six patient surgical records reviewed (ID# 1).

Findings include:

Review of facility Medical Staff Bylaws showed the following:
The privilege to perform medical histories and physical examinations shall be granted to qualified applicants by the board. A medical history and physician examination shall be completed no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services.

Review of medical record for patient (ID # 1) for surgery date of service 12/13/2023 showed no updated History and physical prior to procedure.

Interview with staff (ID#53) on 9/26/23 at 2:30 PM confirmed that if the H&P are completed 30 days prior to date of service the update must be completed after admission and before the surgery.

Based on record review and interview, the hospital failed to ensure that there was a properly executed informed consent for 2 of 6 surgical patient records reviewed (ID#s 3 and 5).

Findings include:

Record review of facility policy titled "Disclosure and Consent for Medical and Surgical Procedures (Informed Consents)" showed the following information:

POLICY:
A. It is the policy of St. Luke's Health (St. Luke's) Texas Division to comply with applicable regulatory and accreditation requirements pertaining to Disclosure and Informed Consent for medical treatment or care and surgical procedures, including specific procedures outlined by:
-Code of Federal Regulations (42 CFR Part 482), CMS Conditions of Participation, Appendix A
-Texas Administrative Code (TAC) Hospital Licensing Rules, Title 25 Chapter 133
PROCEDURES
2. Discussion for Informed Consent

d. Verify that the consent form is completed and patient or his/her surrogate decision maker signed the consent form prior to commencing the medical treatment or surgical procedure.
e. Sign with date and time ...

4. Preparation of the Consent Form
b. Enter the following information on the consent form for the patient or surrogate decision maker to review,

vi. Whether, as permitted by Texas law, qualified non physician healthcare providers (surgical technicians, surgical assistants, CRNAs and or AAs) we'll be performing important tasks that are within their scope of practice, and for which they have been granted privileges by the hospital.
ix. The name of the provider administering the anesthesia and/4 analgesia.

10.Witness
a. A witness to the signature of the patient or his/ her surrogate decision maker is required on the consent form.
c. The witness attest to the fact that the patient or his/ her surrogate decision maker is the person who signed the consent form in his/her presence.
d. Date, time, sign and print his/ her full name, and enter his/her address is provided on the consent form.

Medical record review for patient (ID #3)Disclosure and Consent -Anesthesia for date of service 9/26/23 showed the following:
Physician Anesthesiologist and Certified Registered Nurse Anesthetist was left blank.

Medical Record Review for patient (ID#5) for date of service 9/26/24 showed the following: Disclosure and Consent- Anesthesia- Physician Anesthesiologist and Certified Registered Nurse Anesthetist was left blank.
Disclosure and Consent for Medical and Surgical Procedures showed no witness name, signature and time recorded.


Interview with staff (ID 56) PACU manager on 9/26/24 at 12:37 PM confirmed the above findings.