HospitalInspections.org

Based on medical record review, the facility failed to ensure the medical records were complete.

Findings:

14 out of 29 medical records reviewed lacked a time on the general consent form to identify when the patient or witness signed.

7 out of 15 surgical records reviewed lacked a time, date and/or signature of the patient or surgeon on the surgical consent form.

12 out of 15 surgical records reviewed lacked a time, date and/or signature of the patient or anesthesia practitioner on the anesthesia consent form.

In 3 out of 15 surgical records reviewed the pre-anesthesia exam was not timed.

In 5 out of 15 surgical records reviewed the post- anesthesia exam was not timed.


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Based upon observation and interview facility staff failed to maintain the facility in such a manner as to ensure the safety and well being of patients and staff.

FINDING
On 11/15/11 at 1500 hours during a tour of the operating rooms with the operating room supervisor it was observed that 2 ceramic wall tiles in OR "A" were broken. A ceramic wall with a broken finish has the potential to harbor microorganisms which would remain during routine cleaning.

On 11/16/11 at 1000 hours during interview with the Director of Plant Operations and the Manager of Plant Operations it was acknowledged that broken ceramic wall tiles could not be adequately cleaned to ensure that microorganisms are not retained in the cracks of the tile.

Based on document review and interview the facility's operating room register was not complete.
Finding's
The operating room register did not include the following:
1. The name of nursing personnel, specifically the scrub and circulating Tech/Nurse.
2. Pre and post-op diagnosis.
3. The age of the patient.
4. The name of any assistants.
The lack of information was confirmed by the facility's QA Director and Operating Room Director on 11/16/11 at 1:00 PM.

Based on medical record review staff failed to describe patients' responses to anesthesia.

Findings:

3 out of 15 surgical records reviewed failed to conduct post-anesthesia evaluations consistent with facility policy: "Pre and Post Anesthesia Evaluation."

3 out of 15 surgical records revealed post anesthesia evaluations being conducted less than 15 minutes after the patient left the operating room. One of the three was a bariatric patient who had received general anesthesia..