HospitalInspections.org

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Based on interview, record review and review of policies and procedures, staff failed to followed its policy and procedure for ordering restraints for management of patients exhibiting violent or self-destructive behavior for 2 of 3 patient records reviewed (Patients #302 and #501).

Failure to follow established procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Management," no policy number, effective 02/23/18, showed that a physician order for restraints as a result of violent or self-destructive behavior is renewed every 4 hours for patients age 18 years and older.

2. On 06/19/18 at 10:25 AM, Surveyor #5 and a registered nurse (Staff #508) reviewed the medical record of Patient #501, who was admitted to the Emergency Department (ED) on 06/17/18 for the treatment of paranoid ideation. The medical record review showed:

- On 06/18/18 at 6:00 PM, a physician entered an order for 4-point violent "Tuff Cuff" restraint into the electronic health record. There was no physician or licensed independent practitioner (LIP) renewal order for the patient restraints until 06/19/18 at 3:00 AM. The patient was in 4-point restraints for an additional 5 hours without a physician or LIP order.

3. At the time of the medical record review, a registered nurse, (Staff #508) confirmed the findings and stated that there should have been a physician renewal order.

4. On 06/20/18 at 3:30 PM, Surveyor #3 and a staff member from Quality Management (Staff #307) reviewed the medical records of two patients (#302 and #303) placed in restraints while being treated in the emergency department. The medical record review showed:

-On 01/08/18 at 2:30 AM, a physician entered an order for 4-point restraints into the electronic medical record for Patient #302. The patient remained in restraints and a physician failed to order a renewal of the restraints until 01/08/18 at 8:00 AM, which is 1 hour and 30 minutes beyond the allowed 4-hour time limit.
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Based on interview, record review, and review of the policies and procedures, the hospital failed to ensure that patients placed in restraints or seclusion received a face-to-face assessment within one hour by a physician or licensed independent practitioner as directed by hospital policy for 3 of 3 patients reviewed (Patients #302, #303 and #502).

Failure to perform the required face-to-face evaluation to determine whether the patient actually meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Management," no policy number, effective 02/23/18, showed that following initiation of restraints, the patient must have a medical and behavioral face-to-face evaluation if used to manage violent or self-destructive behavior by a physician or other licensed independent practitioner within one hour.

2. On 06/19/18 at 10:25 AM, Surveyor #5 and a registered nurse (Staff #508) reviewed the medical record of Patient #501, who was admitted to the Emergency Department (ED) on 06/17/18 for the treatment of paranoid ideation. The medical record review showed:

a. On 06/18/18 at 11:12 AM, staff placed the patient in 4-point "Tuff Cuff" restraints for violent or self-destructive behavior. The physician order for restraint stated that a one-hour face-to-face assessment was required.

b. On 06/18/18 at 1:00 PM, staff removed the patient from 4-point restraints and placed him in seclusion. The physician order for seclusion stated that a one-hour face-to-face assessment was required.

c. On 06/18/18 at 2:18 PM, staff removed the patient from seclusion and placed him in 4-point "Tough Cuff" restraints for violent or self-destructive behavior. The physician order for restraint stated that a one-hour face-to-face assessment was required.

d. On 06/18/18 at 6:00 PM, the patient was placed in soft limb restraints for violent or self-destructive behavior. The physician order for restraint stated that a one-hour face-to-face assessment was required.

Surveyor #5 found no evidence that staff performed a 1-hour face-to-face assessment for any episode of restraint or seclusion described above.

3. At the time of the medical record review, a registered nurse, (Staff #508) confirmed the findings.

4. On 06/19/18 at 11:00 AM, during interview with Surveyor #5, the Emergency Room Director (Staff #509) confirmed the finding and stated that there was not a screen built into the electronic medical record system to trigger the one-hour face-to-face evaluation.

5. On 06/20/18 at 3:30 PM, Surveyor #3 and a staff member from Quality Management (Staff # 307) reviewed the medical records of two patients (#302 and #303) placed in restraints while being treated in the emergency department. The medical record review showed:

a. On 01/08/18, at 2:30 AM, emergency department staff placed Patient #302 in 4-point restraints for violent aggressive behavior. The surveyor found no evidence that staff performed a 1-hour face-to-face assessment.

On 01/08/18 at 4:45 PM, staff removed the restraints and placed the patient in seclusion. The surveyor found no documentation to indicate that staff performed a 1-hour face-to face assessment following each restraint renewal order for the previous 12 hours (3 episodes).

b. On 01/25/18 at 2:30 AM, Patient #303 arrived at the emergency department with altered mental status and extreme agitation. The emergency department staff placed Patient #303 in 4-point restraints. The surveyor found no evidence that a physician performed a 1-hour face-to-face assessment as required by hospital policy.

6. On 06/21/18 at 9:15 AM, Surveyor #3 interviewed the Chief Nursing Officer (Staff # 308), a physician (Staff #309) and others about the hospital's restraint and seclusion program. Staff #308 and #309 stated that it was hospital policy for a physician or licensed independent practitioner to perform a 1-hour face-to-face assessment. They stated that the hospital was in the process of implementing a "pop-up" reminder in the electronic medical record to prompt staff to complete the assessment.
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Based on interview, record review and review of policies and procedures, the hospital failed to develop an individualized plan for patient care for 4 of 8 patients reviewed (Patient #502, #505, #506, and #507).

Failure to develop an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient's needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Assessment, Reassessment, and Plan of Care," Policy number 733.10, revised 10/15/16, showed that an individualized care plan must be implemented within 12 hours of admission.

2. On 06/18/18 at 1:32 PM, Surveyor #5 and the Critical Care Manager (Staff # 510) reviewed the medical record of Patient #502 who was admitted on 06/10/18 for the treatment of cardiogenic and septic shock. The patient underwent surgery on 06/10/18 for a right toe debridement and on 06/11/18 for a right below knee amputation. Surveyor #5 found no evidence that the clinical staff had updated the plan of care to reflect the above changes in the patient's medical condition or treatment interventions ordered by the physician.

3. At the time of the medical record review, Staff #510 confirmed the finding.

4. On 06/18/18 at 3:00 PM, Surveyor #5 and a registered nurse (Staff # 512) reviewed the medical record of Patient #505 who was admitted on 04/03/18 for the treatment of respiratory failure. The patient was in droplet isolation for pseudomonas (a type of bacteria) infection and enteric isolation for frequent loose stooling. During the course of the hospitalization, the patient received a gastric tube for tube feedings. She developed red erythematous (inflamed) skin on the coccyx, kidney failure, and was receiving fluid bolus (a large volume of fluid provided intravenously) and medication for low blood pressure. Surveyor #5 found no evidence that staff had updated the plan of care to reflect the changes in the patient's medical condition described above.

5. At the time of the medical record review, Staff #512 confirmed the finding.

6. Review of the care plans for Patient's #506 and #507 showed similar findings.
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Based on interview, document review, observation, and state and federal regulations, the hospital failed to ensure that medication administration that bypassed pharmacist review was restricted to emergencies.

Failure to perform a pharmacist review of medication orders puts patients at risk for medication error and adverse medication interactions.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pharmacist Medication Order Review," Policy number MM 4.10, reviewed 06/19/18, showed that a pharmacist will review all prescription or medication orders before dispensing, removal of floor stock, or removal from an automated storage and distribution device except in situations when the delay could result in harm to the patient or the patient experiences a sudden change in clinical status.

Document review of the hospital's policy and procedure titled, "Automated Drug Dispensing Devices-Policy and Procedures," Policy Number MM 2.20.2, effective date 04/25/18, showed that a pharmacist will perform a prospective drug utilization review of orders prior to their removal from the automated drug dispensing device (ADDD) except if the prescriber is in the immediate vicinity and controls the drug dispensing process.

The policy defined override medications as "those medications that are accessed and removed from the ADDD without prospective pharmacy review". The document review showed that the P&T (Pharmacy and Therapeutics) committee will approve the override medication list and that the list will include any medications that may result in patient harm if there is a delay in administration.

Review of the hospital's document titled, "EvergreenHealth Master Medication Override List-April 2018," included approved medication overrides for departments titled CCU (Critical Care Unit), 4 Silver, 5 Silver, 6 Silver, 8 Silver, 5 blue, OB (Obstetrics) Triage, FMC, 4B NICU (Neonatal Intensive Care Unit), 4B Pediatrics, 4B Women, ARU, and Hospice. The document failed to include an approved override list for the hospital's emergency department.

2. On 06/19/18 at 9:55 AM, Surveyor #5 inspected the hospital's Emergency Department medication room. At the time of the inspection, Surveyor #5 interviewed the Emergency Room Charge nurse (Staff #513) about pharmacy review of medications in the Emergency department and medication overrides. Staff #513 stated that the Emergency Room staff could override all medications in the ADDD. The surveyor observed as the staff member dispensed a stool softener medication using the override process.

3. At the time of the observation, a Quality Specialist (Staff #515) confirmed the finding.

4. On 06/20/18 at 1:00 PM, Surveyor #5 interviewed the Pharmacy Director (Staff #516) and the Pharmacy Manager (Staff #514). At the time of the interview, Staff #514 stated that many of the medications were "auto-verified" and that the Emergency Department was not included in the hospital's override medication list, because providers control the drug ordering and dispensing process.

5. On 06/19/18, Surveyor #5 reviewed a document provided by Staff #514 that showed in part, the pharmacy process for auditing narcotics removed through the override process. The document included a description of an occurrence on 05/23/18, where a narcotic was removed from the ADDD in the Emergency Room via the override process and administered to a patient without a physician order or pharmacy review prior to that administration.
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Based on observation, interview, and document review, the hospital failed to secure medications from unauthorized usage.

Failure to secure medications risks potential diversion, theft, tampering, and patient safety.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Security - Access to Medications," no policy number, effective 05/23/17, showed that staff are to keep medications in a secure area and locked when appropriate. Medications located in operating room suites are considered secured unless not in use. Mobile medication carts are to be locked when not in use.

2. On 06/19/18 at 9:00 AM, Surveyor #3 inspected the ambulatory surgery area. The observation showed a large unlocked mobile cart containing several injectable medications in the perioperative hallway.

At the time of the observation, the surveyor asked the operating room manager (Staff #305) about the unlocked mobile medication cart. Staff #305 stated the hospital was transitioning to an automated medication dispensing system administered by pharmacy. She stated that the hospital had not yet fully implemented the system.

3. On 06/20/18 at 10:36 AM, Surveyor #3 inspected the Comprehensive Procedural Center (CPC). The surveyor observed an unlocked anesthesia cart located in procedural room #2. The room was closed at the time of the observation.

4. At the time of the observation, Surveyor #3 interviewed the CPC Nurse Manager (Staff #306) about the unlocked anesthesia cart. She stated that the anesthesia carts are unlocked at the beginning of day and remain unlocked until the end of the CPC's operating hours.
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Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the expiration date.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, stability or efficacy.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Inspection of Medication Storage Areas," no policy number, effective 06/20/18, showed that the medication safety technician would inspect medication storage areas monthly. The technician will remove all outdated or deteriorated drugs or those due to expire in one month.

2. On 06/18/18 at 2:35 AM, during inspection of post-anesthesia care unit (PACU), Surveyor #3 observed the following:

-One opened 10 ml vial of Humulin-R insulin (medication used to treat high blood sugar) with a pharmacy discard date sticker written 06/14/18.

-One opened vial of labetalol 100 mg/20 ml (medication used to treat high blood pressure) with an unclear opened or discard date and time written.

At the time of the observation, the PACU nurse manager (Staff #305) stated that the medications were beyond their patient use date and removed them.

3. On 06/19/18 at 9:00 AM, during inspection of the outpatient surgery anesthesia workroom, Surveyor #3 observed one 30 ml vial of 1.5 % carbocaine (local anesthetic) with an expiration date of 09/01/17.

4. On 06/19/18 at 2:45 PM, during inspection of the medication room on the 8th floor, Surveyor #3 observed one opened 10 ml vial of Lantus insulin (medication used to treat high blood sugar) with a pharmacy discard date sticker written 06/18/18.

5. On 06/20/18 at 10:25 AM, during inspection of the hospital's Cardiac Cath Lab medication room, Surveyor #5 observed one opened vial of Humulin-R insulin (medication used to treat high blood sugar) with an "open date 05/15/18" written on the label.

At the time of the observation, the Director of Acute Care (Staff #507) confirmed the finding and removed the expired medication.
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Based on observation, interview, and review of policy and procedure, the hospital staff failed to ensure patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.

Failure to ensure that patient care supplies are not expired risks ineffective patient care and treatment, and potential patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Clean and Soiled Utility Room Management," Policy number 10595, revised 05/24/18, showed that each department is responsible to check patient care items on a monthly basis to ensure items are not used past their expiration date.

2. On 06/18/18 at 10:00 AM, during inspection of the perioperative and post anesthesia areas, Surveyor #3 observed:

-One adult multi-functional defibrillation electrodes with an expiration date of 06/15/18.

-Two 14-gauge intravenous catheters with an expiration date of 01/18.

-Three transport sterile swabs with an expiration date of 12/17.

3. On 06/18/18 from 10:35 AM until 11:50 AM, during inspection of the hospital's Critical Care Unit (CCU), Surveyor #5 observed:

-1 bag valve mask (hand-held device used to provide positive pressure ventilation to a patient who is not breathing) with a manufacturer's expiration date of 06/10.

-1 prefilled normal saline syringe with a manufacturer's expiration date of 01/16.

-9 prefilled normal saline syringes with a manufacturer's expiration date of 02/16.

-3 leur lock caps with a manufacturer's expiration date of 08/17.

-1 package of Sage chlorhexidine (CHG) wipes with a manufacturer's expiration date of 12/17.

-1 Avanti introducer set with a manufacturer's expiration date of 01/18.

-1 Micro puncture introducer set with a manufacturer's expiration date of 02/18
-2 temporary pacing catheters with a manufacturer's expiration date of02/28/18.

-1 nylon dilator with a manufacturer's expiration date of 03/18.

-2 Centurion percutaneous sheath + introducer sets with a manufacturer's expiration date of 04/30/18.

-1 Thal-Quik chest tube tray with a manufacturer's expiration date of 06/01/18.

-1 A-Z super stiff straight tip guide wire with a manufacturer's expiration date of 06/04/18.

4. At the time of the observations, the Critical Care Manager (Staff #501) confirmed the findings and removed the expired items.

5. On 06/19/18 at 9:05 AM, during inspection of the hospital's Emergency Room, Surveyor #5 observed:

-7 Massimo oxygen saturation finger probes with a manufacturer's expiration date of 08/17.

6. At the time of the observations, the Emergency Room Manager (Staff #502) confirmed the finding and removed the expired items.

7. On 06/20/18 at 10:35 AM, during inspection of the hospital's Cardiac Cath Lab, Surveyor #5 observed:

-7 Ameriglo emergency glow sticks with a manufacturer's expiration date of 03/12.

-18 boxes of Aqua Blox emergency drinking water with a manufacturer's expiration date of 11/19/13.

-1 FemStop Gold arterial pressure device with a manufacturer's expiration date of 03/07/18.

9. At the time of the observations, the Cardiac Cath Lab Manager (Staff #506) confirmed the finding and removed the expired supplies.
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Based on observation and interview, the hospital failed to maintain cold-holding temperatures of potentially hazardous foods consistent with the Food and Drug Administration (FDA) Food Code.

Failure to maintain cold-holding temperatures of potentially hazardous foods puts patients, staff and visitors at risk of food-borne illnesses.

Findings included:

1. On 06/18/18 at 10:48 AM, Surveyor #2 inspected the nourishment room in the emergency department. During the inspection, the surveyor took the temperature of items in a patient care refrigerator. A carton of milk measured 42.3 degrees Fahrenheit and a container of gelatin measured 46.8 degrees Fahrenheit.

2. The Emergency Department Manager (Staff #201) confirmed the temperatures at the time of observation.

3. On 06/20/18 at 3:25 PM, Surveyor #4 used a thin-stemmed thermometer to assess the internal temperature of several items in the hospital's cafe. The observation showed:

a. raw beef stored in the countertop refrigerator adjacent to the Wok Grill: 54 degrees Fahrenheit

b. a carton of milk in the "grab and go" cooler: 45 degrees Fahrenheit

c. a carton of yogurt in the "grab and go" cooler: 45 degrees Fahrenheit

d. a container of parfait in the "grab and go" cooler: 45 degrees Fahrenheit

All items had an internal temperature above the maximum allowable cold-holding temperature of 41 degrees Fahrenheit. Hospital staff submitted a work order to reduce the temperature of the refrigeration unit during the survey.

Reference: FDA Food Code 2009: Chapter 3 - Food (3-501.16(2)).
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Based on observation, interview and document review, the hospital staff failed to comply with facility policies for infection control designed to prevent infections and communicable diseases in the hospital.

Failure to comply with policies and procedures to prevent transmission of infections puts patients, staff and visitors at risk from communicable illnesses.

Item #1- Hand Hygiene

Findings included:

1. Document review of the hospital policy titled, "Hand Hygiene", (last reviewed 06/07/18), showed that indications for hand hygiene include prior to putting on gloves and after glove removal.

The document review also showed that staff are to wash hands with soap and water prior to leaving patient rooms if the patient is in "contact enteric" isolation.

2. On 06/18/18 beginning at 12:00 PM, Surveyor #3 observed a procedure in the operating room. The observation showed the following:

a. On two separate occasions, a surgical technician (Staff #303) picked an item off the floor and deposited the item into a trash can without performing hand hygiene afterward.

b. A circulator nurse (Staff #304) removed a soiled dressing from Patient #301's leg. The nurse then removed their gloves, did not perform hand hygiene before donning a new pair of gloves, and proceeded with another task.

3. On 06/18/18 at 2:30 PM, Surveyor #4 observed a member of the housekeeping staff (Staff #401) as she completed cleaning a patient room on the 2nd floor post-partum unit. The observation showed that the staff member completed cleaning and removed her gloves. She failed to perform hand hygiene after glove removal. The staff member proceeded to obtain clean items with her bare hands for restocking the patient room.

4. On 06/19/18 at 9:00 AM, Surveyor #4 observed a patient on the 4th floor who was in contact enteric and droplet isolation. The observation showed a nurse (Staff #402) who was attending to the patient exit the room and without performing a soap and water hand wash, used sanitizer from the outside dispenser and entered into the main hallway.

5. On 06/19/18 at 9:20 AM, Surveyor #4 observed a member of the interventional radiology staff (Staff #403) as she exited the room of a patient who was in contact enteric and droplet isolation. The staff member failed to perform hand hygiene after removing her gloves and gown.

6. On 06/19/18 beginning at 12:00 PM, Surveyor #4 observed the dialysis setup for a patient in contact isolation. During the observation, the patient's physician (Staff #404) entered the patient's room. The observation showed that the physician failed to perform hand hygiene prior to putting on her gloves and gown.
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Item #2- Personal Protective Equipment

Findings included:

1. Document review of the hospital's policy and procedure titled, "Personal Protective Equipment PPE," Policy number 28105, revised 09/08/18, showed that the sequence for removing personal protective equipment is to first remove the gloves, then remove the gown, sanitize the hands, remove the mask, remove the face shield and then sanitize the hands.

Document review of the hospital's policy titled, "Transmission Based Isolation Precautions", Policy number 15955, revised 12/05/17, showed that staff are required to wear a gown and gloves whenever they enter the room of a patient on contact enteric isolation. During patient transport, staff should not wear potentially contaminated protective clothing into the hallways.

2. On 06/18/18 at 11:25 AM, during inspection of the hospital's Critical Care Unit (CCU), Surveyor #5 observed a phlebotomist (Staff #503) as she exited an isolation room and removed her personal protective equipment. Surveyor #5 observed Staff #503 remove her mask with contaminated gloves and then remove her gloves.

At the time of the observation, the Critical Care Manager (Staff #501) confirmed the finding and stated that the staff member should have removed her gloves and performed hand hygiene prior to removing her mask.

3. On 06/18/18 at 11:55 AM, Surveyor #5 observed a physician (Staff #504) in an isolation room (room #2522) remove his gloves and then remove his mask. Staff #504 did not perform hand hygiene after removing his gloves, prior to removing his mask.

At the time of the observations, the Critical Care Manager (Staff #501) confirmed the finding and stated that the physician should have performed hand hygiene after removing his soiled gloves, prior to removing his mask.

4. On 06/19/18 at 9:00 AM, Surveyor #4 observed a member of the interventional radiology staff (Staff #405) as he prepared to transport a patient who was on contact enteric and droplet isolation. The observation showed that the staff member failed to tie their gown at the waist prior to entering the patient's room. The surveyor also observed that the staff member's gown came into contact with the patient's bedding several times while he tried to position the patient for transport.

5. On 06/19/18 at 9:20 AM, Surveyor #4 observed a member of the interventional radiology staff (Staff #403) as she prepared to transport a patient who was on contact enteric and droplet isolation. The observation showed that the staff member continued to wear her mask outside of the patient's room after moving the patient onto the gurney for transport.

6. On 06/19/18 at 11:55 AM, during inspection of the hospital's Emergency Department, Surveyor #5 observed a housekeeper (Staff #505) cleaning an isolation room (Room #4026). Surveyor #5 observed Staff #505 place garbage into a garbage can, then reach under her gown with her contaminated gloved hand, and retrieve her phone from the pocket of her scrub clothing.

At the time of the observation, the Emergency Room Manager (Staff #502) confirmed the finding.

7. On 06/19/18 at 1:20 PM on a medical-surgical floor, Surveyor #3 observed a physician (Staff #301) and dietary technician (Staff #302) as they entered a room (#7074) posted for contact isolation precautions. The staff members' PPE was not secure at the waist allowing it to flap freely exposing it to possible contamination by items in the patient's room.

8. On 06/19/18 at 1:25 PM, Surveyor #9 observed a Nursing Assistant-Certified (NAC) (Staff #902) and a Physical Therapist (Staff #903) as they performed skin care and a bed linen change for Patient #906. The patient was in contact isolation due to a diagnosis that included Methicillin Resistant Staph Aureus (MRSA). Staff #902 and Staff #903 were wearing personal protective equipment (PPE) but did not have their gowns tied at the waist.
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Based on interview, medical record review and review of hospital policy and procedure, the hospital failed to provide evidence that the hospital provider contacted the resident or attending physician at the receiving hospital with clinical information and acceptance of transfer as demonstrated by 5 of 6 patient records reviewed (Patients #901, #902, #903, #904, #905).
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Failure to ensure acceptance of a transfer from the hospital to the receiving hospital risks continuity of care and adverse patient outcomes.
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Findings included:
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1. Document review of the hospital's policy and procedure titled, "Patient Transfers to Other Healthcare Facilities," Policy # Adm 136, effective 03/27/15, showed that the provider is to contact the resident or attending physician at the receiving institution.
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2. On 06/20/18 at 1:30 PM, Surveyor #9 reviewed the "Informed Consent to Transfer and Physician Certificate of Transfer," in the medical records of Patients #901, #902, #903, #904 and #905. This review showed that in the medical records for Patients #901, #902, #903 and #904, staff failed to document the name of the receiving provider or the time they contacted the provider. Review of the medical record for Patient #905 showed that the transfer form was missing.
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3. At the time of the review, Surveyor #9 discussed the finding with a member of the Quality Management Team (Staff #901) who stated that the form should be included in the record. She stated that the form should include the name of the receiving provider and the time of the communication between the transferring and receiving provider.
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Based on interview, record review and review of hospital Medical Staff Bylaws, the hospital failed to ensure the pre-operative medical history and physical (H&P) was updated within 24 hours of registration as required by regulation for 2 of 6 patient records reviewed (Patient #503 and #504).

Failure to update the history and physical exam prior to surgery places patients at risk for poor outcomes due to changes in unknown or known co-morbid conditions.

Findings included:

1. Document review of the hospital's "Medical Staff Bylaws," dated 12/15, showed that a history and physical completed within 30 days prior to admission must have an updated medical record entry documenting examination for any changes in the patient condition. The completed history and physical must be on the medical record prior to surgery, invasive procedure, or any procedure that requires anesthesia or conscious sedation.

2. On 06/20/18 at 11:05 AM, Surveyor #5 observed a cardiac catheterization procedure for Patient #503. Review of the medical record showed that staff completed the history and physical on 06/03/18. Surveyor #5 found no evidence that staff completed an update to the history and physical prior to the procedure.

3. At the time of the medical record review, Staff #506 confirmed the finding.

4. On 06/21/18 from 11:00 AM until 12:15 PM, Surveyor #5 and a registered nurse informaticist (Staff #511) reviewed the discharged medical record of Patient #504 who was admitted on 06/08/18 for a cardiac catheterization. Review of the medical record showed that staff completed the history and physical on 05/24/18. Surveyor #5 found no evidence that staff completed an update to the history and physical prior to the procedure.

5. At the time of the medical record review, Staff #511 confirmed the finding.
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Based on interview, record review and document review, the hospital failed to follow policies and procedures for post-anesthesia evaluation that meet the regulation and reflect professional standards of anesthesia care for 1 of 2 patients reviewed (Patient #502).

Failure to perform a comprehensive evaluation of patients recovering from anesthesia places patients at risk of harm related to unrecognized complications of anesthesia and delays in necessary treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Post Anesthesia Evaluation," policy # 2442, effective 05/11/15, showed that an anesthesiologist evaluation is expected on every patient, whether they are inpatient or outpatient within 48 hours following a procedure requiring deep sedation or anesthesia.

Document review of the hospital's "Rules and Regulations," no date, showed that the anesthesiologist must maintain a complete anesthesia record.

2. On 06/18/18 at 1:32 PM, Surveyor #5 and the Critical Care Manager (Staff # 510) reviewed the medical record of Patient #502, who underwent general anesthesia for a right toe debridement on 06/10/18. Surveyor #5 found no evidence that an anesthesiologist completed a post anesthesia assessment.

3. At the time of the medical record review, Staff #510 confirmed the finding and stated that the post evaluation should have been completed.
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