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Based on interview and record review, the facility failed to ensure that nursing services met the needs for 1 of 10 sampled patients (Patient 4). The facility failed to ensure that nursing staff followed the facility practice of providing the patient with a discharge instructions sheet. This failure had the potential to result in the patient not having the information necessary to care of herself post-procedure.

Findings:

A review of the medical record for Patient 4 was conducted on 11/30/11. The review revealed that the patient was admitted to the facility on 11/17/11 for an out-patient procedure for a cataract extraction (removal). The medical record review revealed that the patient was discharged to her home on the same day. During the record review, it was noted that the facility form titled, "Patient Discharge Instructions" was not filled out.

An interview was conducted at the time of the record review on 11/30/11 at 10:30 AM, with the Informatics (Computer) Nurse, RN 2 (Registered Nurse 2). He stated that the facility required the nurse to complete a discharge instruction sheet for all patients being discharged from the facility.

An interview was conducted with the Chief Nursing Officer (CNO) on 11/30/11 at 2:00 PM. She stated that for all patients, in-patient or out-patient, the nurses are taught to complete a discharge instruction sheet. She acknowledged that for Patient 4 the sheet was not completed.

Based on interview and record review, the closed records of 3 of 4 post-surgical patients reviewed (4,5,7) contained entries that were incomplete. One chart (4) contained a Short Stay Admission Form and an Immediate Post Op note that lacked the time of entry. Also, the medication reconciliation form was not filled out. A second chart (5) had a History and Physical that only described a Head and Neck exam and no other systems. A third record (7) contained a Medication Reconciliation Form on which was written, "see attached." The next page was a typed list of the patient's medication but with no information on which medications would be continued or discontinued at discharge. This resulted in a failure of the hospital to be able to provide evidence that the undated, untimed entries occurred in a timely fashion. It also resulted in a failure of the hospital to provide evidence that the medications prior to admission were reviewed by the physician and any changes documented at the time of discharge. The lack of a complete H & P in patient 5 resulted in the possibility that surgery and sedation were performed without knowledge of the general health of the patient on the day of the surgery.

Findings:

1. A list of surgical procedures performed in the previous 2 months was obtained. Four records (4-7) were selected to represent the most common procedures and surgeons with higher volumes of cases. The records were reviewed from the electronic document system with the assistance of RN 2.

2. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" there was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present. A form entitled Immediate Post Operative Note was filled out and signed by the same physician but the DATE/TIME section was blank. A form labeled home Medication Reconciliation Form contained a list of medications but lacked the indication, dose, route, frequency and other information. That area of the form was crossed out with a large squiggly pen mark. The section "Continue on Discharge?", contained a column to circle yes or no, but contained no circles for any of the 9 medications listed.

3. A policy labeled Medication Profile Reconciliation-Continuum of Care (last reviewed 05/2011) was reviewed by the surveyor. It requires a history of all current medications, including drug name, strength, dose, route, frequency, reason for use and time dose last taken. Section 8 states that, "it will be the responsibility of the physician to either print (or request from nursing or pharmacy) and complete an accurate medication reconciliation form at the time of discharge." Section 11 goes on to state that, "On the day of discharge ...the Medication Reconciliation record ...will be printed and checked by the discharging physician or consulting physician to keep them updated on medication changes made in the hospital and improve patient safety."

4. Patient 5 underwent tonsillectomy and adenoidectomy by an Ear, Nose and Throat (ENT) surgeon. The record contained a dictated History and Physical. In the section entitled Physical exam was a detailed examination of the head, eyes, ENT (ears, nose and throat) and the neck. There was no documentation of examination of the heart, lungs, abdomen or other organ systems.

5. The Short Stay History and Physical Examination form was reviewed. RN 2 stated that this would be the minimum expected of a pre-op history and physical. The Physical Exam section contained areas to document vital signs, age, sex, General impression, skin, ears, eyes, nose and throat, chest and lungs, breasts, heart, abdomen, GU/Gyn, extremities and other.

6. A policy entitled Admission of Patient to Operating Room was reviewed. It states that " upon admission of the patient: II. The history, physical and lab results (if ordered) shall be completed and reports shall be attached to the chart. "

7. The record for patient 7 contained a Medication Reconciliation Form( a form filled out by the physician listing the home medications that the physician can mark yes or no for continue on discharge) on which was written " see attached. " The next page was a typed list of the patient ' s medication but with no information on which medications would be continued or discontinued at discharge.

Based on interview and record review, the hospital failed to ensure that in 2 out of 4 (4,5) post-surgical closed records that a complete History and Physical was documented. The record for patient (4) contained a Short Stay admission form that had no documentation of date or time. This resulted in the inability to ensure that the form was completed within the time frame specified in regulation and in the facility policy. The Regulation requires the H & P either within 30 days before surgery with an update on the day of surgery OR completed on the day of surgery. The hospital policy (Physician Medical Record Guidelines reformatted 1/2009) is within 7 days, with an update of the day of surgery. This also made it impossible to ascertain if the information on the form was current, up-to-date and accurate. The medical record for patient (5), a patient admitted for tonsillectomy/adenoidectomy, contained a physical exam by the physician that included only the head and neck. Facility policy and community standards require a complete physical examination before a procedure in which sedation or anesthesia is to be used. This resulted in the possibility that surgery and anesthesia would be performed on a patient with an intercurrent illness or medical problem that might make such a procedure higher risk.

Findings:

1. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present.

2. Patient 5 underwent tonsillectomy and adenoidectomy by an Ear, Nose and Throat surgeon. The record contained a dictated History and Physical. In the section entitled Physical exam was a detailed examination of the head, eyes, ENT (ears, nose and throat) and the neck. There was no documentation of examination of the heart, lungs, abdomen or other organ systems.

3. The Short Stay History and Physical Examination form was reviewed. RN 2 stated that this would be the minimum expected of a pre-op history and physical. The Physical Exam section contained areas to document vital sign s, age, sex, General impression, skin, ears, eyes, nose and throat, chest and lungs, breasts, heart, abdomen, GU/Gyn, extremities and other.

4. A policy entitled Admission of Patient to Operating Room (last revised 3/99) was reviewed. It states that "upon admission of the patient: II. The history, physical and lab results (if ordered) shall be completed and reports shall be attached to the chart."

5. A policy entitled Physician Medical Record Guidelines (last reformatted 1/2009) was reviewed. The section marked Procedures states, " 2. History and Physical Examination ...must include the following:
* Physical examination to include inventory of body systems and vital signs.

Based on interview and record review, the hospital failed to ensure that all entries to the medical record were signed, dated and timed. One chart (4) of 4 post-surgical closed records reviewed contained a Short Stay Admission Form and an Immediate Post Op note that lacked the time and date of entry. This resulted in a failure of the hospital to be able to provide evidence that the undated, untimed entries occurred in a timely fashion.

Findings:

1. Patient Record 4 contained a History and Physical written on a Short Stay Admission Form. The form was filled out and signed by the physician. Next to the preprinted cue "Date/Time:" was handwritten the date but not the time. There was no time of entry anywhere on the form. RN 2 confirmed that the date should have been present.

2. The record for patient 4 also contained a form labeled Immediate Post-Operative Note. The form was filled out and signed but the section on top labeled DATETIME was blank.