HospitalInspections.org

Based on interview and record review, the facility failed to complete post-operative anesthesia evaluations performed three (3) of ten (ten)
patients (ID SL-7, SL-8, and SL-9).

Findings include:

Record review of facility policy titled: Anesthesia Responsibilities dated, 4/2019 showed the following information:

-Postoperative visits must be made by the anesthetist and the patient must be evaluated by a licensed independent contractor, or meet the medical staff approved criteria for discharge, prior to discharge for the post anesthesia care unit (PACU).

-Documentation of the preoperative and postoperative anesthesia visit must be done on the anesthesia evaluation sheet by the attending anesthetist before the patient can be discharged. The anesthetist must be available to see the patients if there are postoperative anesthesia complications in the PACU. The anesthetist is responsible for all preoperative and postoperative care given to patients as related to anesthesia. The PACU nurse and/or the surgical services manager are responsible for informing the anesthetist. Of any untoward effects that a patient may have.

Medial record review for patient (ID SL-9) for date of service 6/30/21 showed a post-anesthesia evaluation with the following information left blank:
Patient evaluation performed in: (a check box for PACU and other are provided.)
B/P (Blood Pressure)
HR (heart Rate)
TEMP (temperature)
SPO2% (Oxygen level)
The form was signed, dated but not timed.

Medical record review for patient (ID SL-7) for date of service 6/30/31 showed a post- anesthesia evaluation with the following information left blank:
Patient evaluation performed in: (a check box for PACU and other are provided.)
B/P (Blood Pressure)
HR (heart Rate)
TEMP (temperature)
SPO2% (Oxygen level)
The form was signed, dated but not timed.

Medical record review for patient (ID SL-8) for date of service 6/20/21 showed a post-anesthesia evaluation left completely blank with nothing other than a patient identification sticker and anesthesia signature. There was no time, date or documentation of a post-anesthesia evaluation.

Interview with operations manager (ID SL-A) on 7/14/21 at 1:30 PM, she stated that the anesthesia providers are to complete the post-anesthesia evaluation before the patients are discharged.