HospitalInspections.org

Based on interview and record review, the facility failed to ensure the maintenance of an accurately written medical record in one of ten sampled patients. (#1)

Findings:

A review of the medical record for patient #1 was performed. The document Admission (Discharged) in AdventHealth Celebration Operating Room, which included a section for History and Physical which read: "History of Present Illness: This is a . . . -year-old male with elevated PSA (prostate specific antigen) and abnormal prostate MRI (magnetic resonance imaging). He presents for MRI fusion prostate biopsy." This History and Physical was entered by A-Physician on 7/21/23 at 7:24 AM.

The section Medication Administration Record had an entry by A-RN which read: "Peripheral IV 07/21/23 Left Posterior hand." and under the column "Med Links Info", pertaining to this entry, noted it read: "07/21/23 08:03 AM by (A-RN)."

Review of the IV assessment indicated that the left hand placement of a peripheral IV was performed at 8:03 AM.

Continued record review indicated at 8:06 AM: "Timeout type: Preprocedure Checklist" and included confirmation of patient and procedure.

The Anesthesia Information indicated that anesthesia began at 8:10 AM when the anesthesia provider assumed patient care.

An entry by A-CRNA (Certified Registered Nurse Anesthetist) of 7/21/23 at 8:11 AM read: "Size: 18 G. Laterality: right. Location: wrist." and indicated this was done by the CRNA with no mention of why the creation of a new venous access site was done or needed.

The anesthesia record indicated that Propofol was given at 8:15 AM with an entry at 8:15 AM reading: "Sedation induction. Patient was reevaluated immediately prior to induction."

Under the section Medications, it indicated that Propofol was administered by the CRNA at 8:15 AM. However, the section Anesthesia Information read at 8:17 AM: "Anesthesia ready.", noting this was after Propofol had started and indicating the patient had achieved sedation, thus, Propofol was documented as being given at 8:15 AM, after the site change to the right wrist.

Review of the Surgery Information noted a start time of 8:19 AM. The section for Medications indicated that Propofol was stopped at 8:36 AM and the section Surgery Information noted an end time of 8:38 AM. The section Anesthesia Information read at 8:44 AM: "Anesthesia stop.", however the section for Anesthesia Information indicated at 8:40 AM "Patient out of room."

The preceding chronology of events extracted from the medical record was contradicted during an interview of A-CRNA on 10/18/23 at approximately 11:10 AM. He stated the Propofol infusion was actually started in the left hand site (not the right wrist site) and that it ran for about five minutes. However, the record indicated that a right wrist site was placed at 8:11 AM and that Propofol was given through it at 8:15 AM. Also, he stated that after he concluded and sedation was attained, the procedure began with probe insertion. He continued to say that soon afterwards infiltration in the original left hand site was noticed and it was then they initiated a right wrist site, and resumed the Propofol infusion at the new location. However, the record revealed that the surgical procedure began at 8:19 AM, with the Propofol already infusing into the right wrist site, not the left hand site as stated in interview with A-CRNA.

Documentation of the chronology of events as indicated in the record was noted to be inaccurate and interview with Risk Manager on 10/18/23 at approximately 2:00 PM confirmed these findings.