HospitalInspections.org

Based on medical record (MR) review, document review, and interview, in 7 of 8 MRs (Patient's #1, #2, #3, #4, #5, #6, #7), the anesthesia consent forms lacked the name of the certified registered nurse anesthetist (CRNA) performing the anesthesia service and the signature of the anesthesiologist was not legible. Additionally, the hospital's policy and procedure (P&P) lacked instruction to staff to document the name of the provider administering anesthesia on the consent. This lack of documentation does not portray the actual care provided to the patient.

Findings include:

-- Review of Patient #1's MR revealed, their anesthesia consent form dated 7/26/2024 at 10:30 am, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #2's MR revealed, their anesthesia consent form dated 9/20/2024 at 5:30 am, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #3's MR revealed, their anesthesia consent form dated 12/23/2024 at 7:07 am, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #4's MR revealed, their anesthesia consent form dated 9/30/2024 at 2:01 pm, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #5's MR revealed, their anesthesia consent form dated 10/13/2024 at 7:01 am, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #6's MR revealed, their anesthesia consent form dated 10/4/2024 at 2:26 pm, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of Patient #7's MR revealed, their anesthesia consent form dated 12/31/2024 at 5:30 am, lacked documentation of the name of the CRNA that provided anesthesia services to the patient and the anesthesia provider's signature was not legible.

-- Review of the facility's P&P titled "Consent for Anesthesia," publish date 11/25/2022, lacked instruction to staff to identify the provider who would be providing the anesthesia to the patient during their procedure.

-- During interview of Staff A on 1/8/2025 at 11:00 am, they acknowledged the above findings.