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Based on medical record reviews, the facility failed to ensure that a post anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, for 4 (Patients #1, #2, #3, #10) of 10 patients' records.

Specifically, for the following post-anesthesia evaluations conducted, one evaluation had no time recorded, three were conducted at the conclusion of anesthesia administration, one evaluation was conducted one minute after the conclusion of anesthesia administration and the details of the post-anesthesia evaluations were not documented.

Findings include:

A.) For Patient #1, medical record review indicated that on 9/14/2011, the Patient had right breast lumpectomy and was administered general anesthesia from 2:47 PM to 4:35 PM during the operation. The post-anesthesia evaluation documented by the anesthesiologist did not include the following information: 1) the note was not timed 2) the Patient's respiratory rate, oxygen saturation, blood pressure, pulse and temperature were not recorded and 3) the Patient's postoperative hydration status was not documented.

Patient #1 was administered anesthesia on 9/26/11 from 10:45 AM to 11:47 AM. The post anesthesia evaluation was performed by the anesthesiologist at 11:48 AM. The post-anesthesia evaluation documented by the anesthesiologist did not include the following information: 1) the Patient's mental status was not recorded 2) the Patient's respiratory rate, airway patency, oxygen saturation, blood pressure, pulse and temperature were not recorded and 3) the Patient's postoperative hydration status was not documented.


B.) For Patient #2, medical record review indicated that on 7/11/11, the patient had a left breast lumpectomy and anesthesia was administered from 10:22 AM to 11:15 AM. The post anesthesia assessment documented by the Certified Registered Nurse Anesthetist [CRNA] at 11:15 AM did not include the following information: 1) the Patient's mental status 2) the Patient's respiratory rate, airway patency, oxygen saturation, blood pressure, pulse, temperature and 3) the Patient's postoperative hydration status was not documented.

C) For Patient #3, medical record review indicated that on 7/11/11, the Patient had a left breast lumpectomy and anesthesia was administered from 1:15 PM to 3:07 PM. The post anesthesia evaluation performed at 3:07 PM indicated that the Patient could be discharged to home and there were no complications. The post anesthesia assessment documented by the Certified Registered Nurse Anesthetist [CRNA] did not include the following information: 1) the Patient's respiratory function including respiratory rate, airway patency and oxygen saturation, 2) cardiovascular function, including pulse rate and blood pressure 3) mental status 4) temperature 5) pain level 6) nausea and vomiting and 7) the Patient's postoperative hydration status was not documented.


D.) For Patient #10, medical record review indicated that on 8/29/2011, the patient had a left breast lumpectomy and was administered anesthesia from 9:01 AM to 10:22 AM. The post anesthesia evaluation performed at 10:22 AM indicated the patient could be discharged to home and there were no complications. The post anesthesia assessment documented by the CRNA did not include the following information: 1) the Patient's respiratory function including respiratory rate, airway patency and oxygen saturation, 2) cardiovascular function including pulse rate and blood pressure 3) mental status 4) temperature 5) pain level 6) nausea and vomiting and 7) the Patient's postoperative hydration status was not documented.