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Based on interview and medical record review for one of 13 patients reviewed (Patient 179), the surgeon's preoperative history and physical examination did not reflect a complete assessment of the patient's medical history, creating an increased risk of a poor surgical outcome.

Findings:

The hospital's medical staff P&P Medical Record Documentation, last reviewed 10/20/10, read in part, "Outpatients who are scheduled for procedures or operations to be performed under general, regional or epidural anesthesia or deep sedation must have, at a minimum, an electronic short form history and physical exam completed..."

During a review of the medical record of Patient 179 on 8/21/12, the patient's History and Physical Examination dated 8/1/12, signed by the surgeon on 8/6/12, did not show documentation of the patient's psychiatric history, nor information about any medications the patient was taking.

The nursing Admission History-Preop Interview dated 8/1/12, included the information the patient had a psychiatric disorder and was under a psychiatrist's care. The electronic medical record contained a medication list which included the medication gabapentin (a medication used for several conditions, including anxiety associated with other disorders).

During an interview with MD J and MD E on 8/22/12 at 1600 hours, both staff stated physicians did not routinely review nursing documentation prior to surgery. They confirmed the pre-operative history and physical examination completed by the surgeon for Patient 179 did not include an expected notation of the patient's medications. There was no documentation to show the patient was not taking medications.

Review of the anesthesia record showed Patient 179 received general anesthesia for the surgery. In the recovery area after the surgery, the patient was noted to be "unable to stop crying," "felt shaky and nervous," and required four doses of medication for anxiety. On the night subsequent to her discharge Patient 179 presented at the emergency room with a complaint of "severe anxiety due to her inability to take her regular dose of gabapentin for 30 hours." The emergency room physician documented Patient 179 was taking four medications.

Based on interview and record review, the hospital failed to ensure a physician's post-operative medication order was dated and timed for one of 67 sampled patients (Patient 179). This failure created the risk of a medication administration error and poor health outcome for that patient.

Findings:

The hospital's medical staff policy, Medical Records dated 7/26/12, read in part, "Medication orders shall include the name of the drug, the dosage and the frequency of administration, the route of administration, if other than oral, and the date, time and signature of the ordering physician."

The medical record of Patient 179 from an 8/2/12, surgery was reviewed on 8/21/12. A written physician's order for "Lortab elixir (a strong liquid pain reliever) two tsp (teaspoons) now" was reviewed. There was no date or time to show when the order was written.

During an interview with the Surgical Services Clinical Informatics RN on 8/21/12 at 1420 hours, the RN confirmed the order should have been dated and timed when written.

Based on interview and record review, the hospital failed to ensure the nutritional needs of one of 10 patients reviewed (Patient 154) when the low protien diet served was not in accordance with the orders of the practitioner responsible for the care of the patient. Failure to implement a physician's therapeutic diet order had the potential to compromise patient's medical status.

Findings:

On 8/20/12 at 1345 hours, the medical record for Patient 154 was reviewed. Documentation showed that as of 8/18/12, the patient was prescribed a Low Protein diet. On 8/20/12 at 1400 hours, review of the diet manual addendum created by hospital staff, showed a Low Protein diet was defined as one that provided 60 grams of protein.

On 8/20/12 at 1600 hours, a printout of Patient 154's menu, including breakfast, lunch, and dinner was provided. The menu detailed the amount of protein served to the patient based on the patient selection and modifications incorporated by the hospital menu system. The following was noted:

Breakfast: 18 grams
Lunch: 21 grams
Dinner: 21 grams
Total: 60 grams

The computer printout did not take into account protein amounts that would be provided in the starch, vegetable and dessert components of the meals also served to the patient. Based on the patient meal selection, that would be approximately 16-17 additional grams of protein.

On 8/21/12 at 0930 hours, the Director of Foodservices, accompanied by a hospital dietitian, acknowledged the established menu system did not account for the protein content of the starch, vegetable and dessert menu selections and that a range up to 81 grams of protein was permitted for daily meal selection on a low protein diet. Both staff stated the system would be changed to accurately reflect prescribed physician orders.

Based on interview and record review, the hospital failed to ensure anesthesiologists provided care consistent with the needs of two of the13 patients reviewed (Patients 137 and 174). For Patient 137, the anesthesiologist failed to coordinate post-operative medication orders with those of the surgeon. For Patient 174, the anesthesiologist failed to document intra-operative fluid administration. These failures had the potential for an increased risk of a poor post-surgical outcome for those patients.

Findings:

1. The hospital's P&P Recovery of Patients Outside of the PACU review date 11/10, read in part, "Responsibilities of the Anesthesiologist...Post anesthesia and respiratory orders to be coordinated with surgeon."

The medical record of Patient 137 was reviewed on 8/20/12. The patient was transferred to the ICU for recovery after neurosurgery on 8/16/12. A neurosurgeon's order dated 8/16/12 at 1530 hours, in the electronic medical record showed propofol was to be administered with an initial rate of 10 mcg per kilogram per minute with instructions to titrate (adjust dose) every 10 minutes for a sedation score of BIS 50-85 (bispectral index score-reflects the degree of sedation). The paper medical record contained a handwritten order by the anesthesiologist dated 8/16/12 at 1612 hours, (42 minutes later) for propofol at a rate of 100 mcg per kilogram per minute with no titration parameters (no instructions for adjusting the dose).

During an interview with MD J, the Director of Anesthesia on 8/21/12 at 1420 hours, he stated the anesthesiologist was probably unaware of the other orders for propofol written in the electronic health record by the surgeon. MD J confirmed the anesthesiologist was able to access the surgeon's orders for viewing. MD J stated he saw the need for additional clarity in the writing of the medication orders.

2. The hospital's medical staff P&P, Anesthesia and Analgesia effective date 1/18/12, read in part, "Monitoring shall be documented on an intra-operative/intra-procedure anesthesia record. This documentation shall address at minimum: ...Name and amounts of IV fluids.."

The medical record of Patient 174 was reviewed on 8/21/12 at 1300 hours. There was no documentation by the anesthesiologist regarding intra-operative fluid administration.

During a concurrent interview with the Surgical Services Clinical Informatics RN, she stated there was documentation of a bag of IV fluid hung pre-operatively for Patient 174 and a there was documentation of the IV fluid in the PACU area by the nurse; however, there was no documentation by the anesthesiologist of the fluids administered. The RN stated the amount of IV fluid administered to the patient should be documented.

Based on interview and record review, the hospital failed to ensure an anesthesiologist provided a pre-anesthesia assessment reflecting the risks for anesthesia for one of the 13 patients reviewed (Patient 179) creating the risk of a poor post-anesthesia outcome for that patient.

Findings:

The hospital's medical staff Analgesia and Anesthesia P&P effective 1/18/12) read in part, "...the pre-anesthesia evaluation of the patient should include at a minimum: Review of the medical history, including anesthesia, drug and allergy history..."

During a review of the medical record of Patient 179 on 8/21/12, the patient's pre-anesthesia H&P on the anesthesia record for the 8/2/12, surgery did not contain history regarding the patient's psychiatric history nor information about medications the patient was taking. The space available to document medications was left blank.

The nursing Admission History- Preop Interview dated 8/1/12, included the information the patient had a psychiatric disorder and was under a psychiatrist's care. The electronic medical record contained a medication list which included the medication gabapentin (a medication used for several conditions, including anxiety associated with other disorders).

During an interview with MD J and MD E on 8/22/12 at 1600 hours, both staff stated physicians did not routinely review nursing documentation prior to surgery. They confirmed the pre-operative history and physical examination completed by the surgeon for Patient 179 did not include an expected notation of the patient's medications. There was no documentation to show the patient was not taking medications.

Review of the anesthesia record showed Patient 179 received general anesthesia for the surgery. In the recovery area after the surgery, the patient was noted to be "unable to stop crying," "felt shaky and nervous," and required four doses of medication for anxiety. On the night subsequent to her discharge Patient 179 presented at the emergency room with a complaint of "severe anxiety due to her inability to take her regular dose of gabapentin for 30 hours." The emergency room physician documented Patient 179 was taking four medications.