HospitalInspections.org

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Based on observation, interview and document review, the facility failed to assess and document post-surgical discharge criteria on outpatient cataract patients receiving oral sedation.
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Failure to assess and document post-surgical discharge criteria, places patients at risk for complications resulting from untimely or early discharge to the home setting.
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Findings include:
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1. The facility policy "Criteria for Discharge from PACU Phase II to Home " (revised 08/2015) stated in part "B. 1. Each patient must meet the discharge criteria approved by the medical staff and compliance with criteria shall be fully documented in the medical record. "
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2. On 11/09/2016 at 12:30 PM, the Ambulatory Surgery Assistant Manager (Staff Member # 4) was interviewed. Staff Member #4 indicated that the Post Anesthetic Discharge score (PADS) was used to determine if Phase II discharge criteria was being met for outpatients prior to leaving the Post Anesthesia Care Unit (PACU), Phase II.
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3. On 11/09/2016, at 12:30 PM, Investigator #2 observed Patient #7, being discharged from the Post Anesthesia Care Unit, phase II unit without a PADS score. A review of Patient #7's medical record revealed the PADS score was not present.
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4. On 11/09/2016, Investigator #2 reviewed 6 closed medical records of outpatients who underwent cataract surgical procedure. Four of the six patients (Patients # 3, 4, 5) did not have a PADS score documented in their medical record. The three patients who did not have the PADS score documented in their medical record prior to discharge had received oral sedation.
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5. On 11/09/2016, at 2:00 PM, the PICIS Clinical Lead (Staff Member #11) was interviewed while navigating the electronic medical record for Investigator #2. Staff Member #11 stated that the staff did not document the PADS score for outpatient surgery patients who only received oral sedation. Staff Member #11 stated that these patients were viewed as " clinic patients with a minor procedure rather than postoperative surgery patients.
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6. The above findings were verified with the Ambulatory Surgery Center Manager (Staff Member #2).