HospitalInspections.org

Based on medical record reviews and staff interviews, the facility failed to ensure pre-surgical assessments were completed prior to surgery to update the history and physical for 2 of 10 sampled patients (#5, #6).

The findings include:

Review of the medical record for Patient #5 revealed she was scheduled for a coronary artery bypass in the Cardiovascular Operating Room (CVOR) on 5/30/14. The history and physical was dated 5/14/14. There was no documentation of the physician completing a pre-surgical assessment on the day of surgery to update the history and physical.

Review of the medical record for Patient #6 revealed he was admitted to the facility on 7/14/14. He was scheduled to have a left carotid endarterectomy in the CVOR on 7/18/14. The History and Physical was dated 7/15/14. There was no documentation of the physician completing a pre-surgical assessment on the day of surgery to update the history and physical.

Interview with the Director of Surgical Services on 8/12/14 at 12:00 pm revealed the surgeons operating in the Main OR have to complete a pre-surgical assessment on the day of the procedure to update the history and physical. She stated if the patient is an inpatient, a progress note made on the day of surgery would count. She reviewed the medical record for Patients #5 and #6, but did not find documentation were she would expect it to be entered. She stated it is a separate paper form that is filled out and then scanned into the record. She suggested that maybe the CVOR documented it in a different way and she was not as familiar with their process since their director left and she is covering for them. She called CVOR and had the Nurse Manager look for any documentation. The CVOR Nurse Manager reviewed the medical records and did not find the documentation. She stated she has seen some doctors do a pre-surgical assessment, but not others; however, she is not always around when it would be done. It was suggested that it may be a problem with scanning the medical record. The Medical Records Clerk was phoned and asked to find the documents. She reviewed the scanned documents and did not find the pre-surgical assessment sheets.

Based on medical record reviews and staff interviews, the facility failed to ensure an accurate Informed Consent was signed and on the medical record prior to surgery for 1 of 10 sampled patients (#1).

The findings include:

Review of the medical record for Patient #1 revealed she came to the facility on 4/28/14 for a surgical procedure. The Surgical Consent read "Port placement, temporal artery biopsy." The port placement had a line drawn through it and initialed. There was no note of what side the temporal artery biopsy was to be performed. The surgery schedule for 4/28/14 listed Patient #1 having bilateral temporal artery biopsies. The pre-operative anesthesia record listed the planned procedure to be a port placement and temporal artery biopsy. There was not a side indicated for the biopsy and the port placement was not removed.

The intra-operative record revealed the patient was taken to OR #7 on 4/28/14 at 1:30 pm. A safety time-out was documented at 1:48 pm. The time-out includes verification of the procedure Consent vocally with Operative/Procedural team just prior to the procedure start. The procedure was listed as temporal artery biopsy, and a procedure-free text listed bilateral temporal artery biopsy. There was no documentation of a discrepancy in the signed Consent.

Interview with the Risk Manager and the Director of Surgical Services on 8/12/14 at 12:00 pm confirmed Patient #1 did not have an accurate Consent signed for surgery.