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Based on the certification survey completed on September 10, 2015, the facility was found not in compliance with Life Safety Code requirements at CFR §485.623(d).

Refer to Life Safety Code deficiencies at regulations: K-0018, K-0025, K-0029, K-0050, K-0056, K-0072.

Based upon interview, record review, and document review, the acute care hospital did not ensure a comprehensive post-anesthesia evaluation was completed for 4 of 4 surgical inpatients (P19, P21, P22, P23) and for 1 of 1 surgical outpatient (SP1) whose records were reviewed. This had the potential to affect any patient who had anesthesia at the hospital.

Findings include:

P19 had an inpatient surgical procedure under general anesthesia on 9/9/15. Although the Anesthesia Postoperative Note was completed by physician (MD)-A on 9/10/15, at 11:18 a.m., it did not include a comprehensive assessment of the patient's post-anesthesia status. The assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.

P21 had an inpatient surgical procedure which required general anesthesia on 9/6/15. Although the Anesthesia Postoperative Note was completed by certified nurse anesthetist (CRNA)-A on 9/7/15, at 3:16 p.m., it did not include a comprehensive assessment of the patient's post-anesthesia status. The assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.

P22 had an inpatient surgical procedure which required spinal anesthesia on 9/1/15. Although the Anesthesia Postoperative Note was completed by MD-A on 9/1/15, at 8:46 a.m., it did not include a comprehensive assessment of the patient's post-anesthesia status. The assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.

P23 had an inpatient surgical procedure which required general anesthesia on 9/8/15. Although the Anesthesia Postoperative Note was completed by MD-A on 9/10/15 at 3:04 p.m., it did not include a comprehensive assessment of the patient's post-anesthesia status. The assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.

Surgical outpatient (SP)-1 had a surgical procedure under general anesthesia on 9/8/15. Although the Anesthesia Postoperative Note was completed by MD-A on 9/8/15, at 10:58 a.m., it did not include a comprehensive assessment of the patient's post-anesthesia status. The assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.

MD-A was interviewed on 9/9/15, at 10:45 a.m. and stated the template for the post-anesthesia note in the electronic medical record did not include all elements of a comprehensive post-anesthesia evaluation. The physician stated the assessment did not include an assessment of the patient's mental status, pain level, presence/absence of nausea and/or vomiting and post-operative hydration.
A review of the anesthesia department policy, titled Documentation Requirements, last revised September 2012, indicated the Post-Anesthesia Evaluation/Documentation Policy was to include an evaluation which included respiratory function (including respiratory rate, airway patency, and oxygen saturation), cardiovascular function (including pulse rate and blood pressure), mental status, temperature, pain, nausea and vomiting, and post-operative hydration.