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Based on record review the registered nurse failed to ensure nursing documentation for 1 of 20 patients (#1) was done from admission to discharge. This type of practice puts all patients at risk for incorrect, and inaccurate information, potentially resulting in errors of care for the patients.


Findings:

Review of patient #1's record revealed the patient was admitted to the hospital on 05/07/09, with a surgical repair of his/her left humeral fracture.


Review of nursing documentation on a Preoperative Phase/ Preoperative Note dated 05/07/09, at 7:40 AM, indicates the patient oxygen saturation (O2 sats) were 74 %, that the patient was breathing on room air, and a statement that this patient's mother had informed them that this patient stops breathing in his/her sleep. Under the remarks of medications (meds) given, a notation was written "patient placed on 3 Liters (L) of oxygen (O2) via nasal cannulae (NC), O2 increased to 92%." There was no date or time as to when the O2 was placed.

No further documentation was found in patient #1's medical record on 05/07/09 reflecting that this nurse informed or communicated to any physician or anesthesiologist of this patients O2 oxygen saturation of 74%.

Interview on 02/22/10 at 3:30 PM with the anesthesiologist that presided on this case on 05/07/09 with patient #1 revealed that he did not remember when or if the nurse informed him of the low O2 saturation of 74%. He confirmed that he could not find any nursing documentation that the nurse reported to the anesthesiologist of the low O2 saturation.


Interview on 02/22/10 at 4:00 PM with the Administrator of the Operating Room revealed that she confirmed that she could not find any documentation of the nurse notifying the physician of the low O2 saturation of 74%.

Based on medical record review of 1 of 20 records (patient #1) revealed the anesthesiologist failed to document any complications or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient's response to treatment. Failure to document any complications or problems during anesthesia has the potential of preventing the patients from receiving needed care and/or treatment.


Findings:

Medical record review of patient #1's medical record revealed that she/he was admitted for surgical repair of a fracture of his/her left humerus. Patient #1 was taken to the operating room where she/he was consulted for vent management and had a prolonged stay in the operating room with multiple complications while on mechanical ventilation, and was extubated and re-intubated two additional times. Further record review revealed that during the peri operative period for this patient, the anesthetist failed to document these difficulties of extubation or reintubation. Also no documentation was found reflecting a report to the Post Anesthesia Care unit (PACU) the difficulty the anesthetist had on extubation or the reason for the need for reintubation. Review of the anesthesia notes signed by the anesthesiologist dated 05/07/09 states that this patient had "Satisfactory recovery from anesthesia without complication."

Review of the Anesthesia Pre Assessment done on 05/07/09 at 8:20 AM by the anesthesiologist failed to note this patients history of sleep apnea, obesity, or that she/he was mentally challenged.