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Based on clinical record reviews and interviews the facility failed to ensure post anesthesia evaluations completed and documented by an individual qualified to administer anesthesia, within forty eight hours after surgery for 2 of 10 sampled patients. (Patient # 4 and Patient # 7).

The findings include:

Record reviews conducted on 10/30/12 revealed Patient # 4 and Patient # 7 underwent surgical procedures on 07/06/12 and 08/30/12 respectively.

Further review of these records failed to provide post anesthesia assessments.

Interview with the Assistant Director of Surgical Services was conducted on 10/29/12 at 4:30 PM. The Assistant explained pediatric open heart patients do not go to the PACU (post anesthesia recovery unit), patients are recovered in the pediatric intensive care unit; the post anesthesia assessments are usually noted on the second page of the form titled Surgery Anesthesia Perioperative Assessment Safety Checklist; or the anesthesiologist writes a progress note. The Assistant reviewed the electronic clinical records and was unable to produce post anesthesia assessments for Patient # 4 and Patient # 7.

Facility policy titled " Documentation of Anesthesia Care " last revised on 03/17/04 documents " Documentation is a factor in the provision of quality care, and is the responsibility of an anesthesiologist and/or CRNA (Certified Registered Nurse Anesthetist). While anesthesia care is a continuum, it is usually viewed as consisting of pre-anesthesia, peri anesthesia and post anesthesia components. Anesthesia care should be documented to reflect those components and to facilitate review. The record should include documentation of Post anesthesia evaluation including post anesthesia visits.