HospitalInspections.org

Based on interviews with staff, review of the by laws of the organized medical staff and the physician privilege book in the OR (operating room), the Governing Body failed to assure that the medical staff delineated privileges for 2 of 3 physicians in the OR, and failed to assure that the Certified Registered Nurse Anesthetist (CRNA) has current privileges. This impacted 2 of 3 physicians in the OR and the Certified Registered Nurse Anesthetist (CRNA).

Findings:

1) On 6/27/12 at approximately 2:20 pm, an interview was conducted with the COO (Chief Operating Officer)/Administrator. He was asked if he could provide documentation that Physicians #1 and #2 were delineated to perform esophagogastroduodenoscopys (EGD) and colonoscopies in the OR. He stated, "no, I can't".

2) On 6/26/12 at approximately 10:15 am, an interview with Employee E was conducted. He was asked if he schedules the cases after they have been approved financially and he stated that he does. He was asked how he verifies that the physician doing the case is privileged in the procedure he is doing and he stated, " I have a book that has that information listed". I asked him if he actually uses that book and he replied, "do you want me to be honest"? I told him to absolutely be honest and he stated, "I never look at that book".

3) On 6/26/12 at approximately 10:30 am, review of the physician privilege book in the Operating Room was conducted. Documentation revealed that Physician #1 and Physician #2 were not privileged to perform EGD's or colonsocopies. Review of the OR schedule revealed that both physicians are performing the procedures.

4) On 6/28/12, review of the bylaws of the medical staff revealed that the privileges delineated for Physician #1 and Physician #2 did not include EGD's and colonoscopies.

5) On 6/28/12, at approximately 1:00 pm, an interview was conducted with the Risk Manager/QA officer. She was asked if she could produce documentation that the CRNA was currently privileged to practice in the hospital. She stated, "no, it's not there".

6) On 6/28/12 at approximately 12:15 pm, review of the personnel file of the CRNA was conducted. Documentation revealed that he was granted temporary privileges upon hire in February, 2011, and per the medical bylaws, temporary privileges are for 2 months. Documentation revealed that his privileges have not been continued since the initial temporary granting, and that he is currently practicing without having privileges to do so.

Based on interview and facility record review, the hospital failed to ensure the medical staff performed procedures in which they have been granted privileges to perform. This impacted 2 of 3 physicians in the OR and the Certified Registered Nurse Anesthetist (CRNA).

The findings include:

1. On 06/26/2012 at approximately 4:00pm, with the assistance of the Administrative Assistance/Human Resource Superivor, the medical staff record for physician #1 was reviewed. The physician, a surgeon was granted privileges by the Medical Staff and Governing Board for Active Privileges in Emergency and General Surgery on 11/30/2011. The Delineation of Surgical Privileges form, filled out by the requesting physician failed to include Colonoscopy and Upper Endoscopic procedures. Physician #1 was not granted privileges to include Colonoscopy and Upper Endoscopic procedures. Noted on the surgery schedules were Colonoscopy and Upper Endoscopic procedure performed by this physician.

On 06/27/2012 the medical staff record for physician #2 was reviewed. Physician #2 was reappointed and granted active privileges effective July 27, 2011. Physician # 2's delineation of Surgical privileges form, completed by the requesting physician failed to include Colonoscopy and Upper Endoscopic procedures. Physician #2 did not have privileges to perform these procedures. Noted on the surgery schedule, past and present, were Colonoscopies and Upper Endoscopies scheduled and performed by physician #2.

2. On 06/27/2012 at approximately 08:45am an interview was conducted with the preop Registered Nurse (R.N.) responsible for scheduling surgical procedures and assuring that physicians have privileges to perform procedures they are requesting to perform. He stated there is an OR Log Book that indicates the physicians and their privileges, but he has not looked at it. The R.N. did not know that Physician #1 and Physician #2 did not have privileges to perform Colonoscopies or Upper Endoscopies.

3. 06/27/2012 at 09:15am interview conducted with the Risk Manager. She stated that the OR Supervisor is responsible for ensuring the physician has privileges - that they are such a small place that they usually know what the physician can and cannot do. If they were to come across a physician wanting to do something they are not credentialed for it would be brought to the attention of Director of Nurses (DON) or to Administration.

4. On 06/27/2012 at approximately 2:20pm an interview was conducted with the Administrator. He was not aware that Physician #1 and #2 were not given privileges to perform Colonoscopy or Upper Endoscopic Procedures. He felt this was an oversight. Temporary Privileges would be granted right away.

5. On 06/27/2012 the medical staff record for the Certified Registered Nurse Anesthetist was conducted. The record reveal that he had been granted temporary privileges in January 20, 2011 and none since then.

6. The facility's medical staff bylaw were reviewed. The Bylaws indicate on page 19, under the section for Allied Health Professionals "7. Temporary Clinical Privileges....The Temporary Clinical Privileges is not to exceed two (2) months." The Bylaws indicate page 31, "Article VII, Clinical Privileges... 1. Exercise... a. Every Practitioner providing Clinical Services at the Facility, except as expressly provided in these Bylaws, will be entitled only those privileges specifically granted to him/her by the Board."

Based on facility record review and Medical Staff Bylaw review, the facility failed to ensure the a medical history and physical was completed and documented no more than 30 days before or 24 hours after admission/registration, but prior to surgery or a procedure requiring surgery. This impacted one of 30 sampled patients.

The findings include:

1. On 06/26/2012 at approximately 1:40pm, an open record review was conducted for patient # 22, who had undergone surgery on 06/25/2012. The patient had a medical history and physical, dated 05/16/2012 on her chart. The history and physical failed to be updated and was not within 30 days. This was confirmed with the acting Unit Manager.

2. The facility's Medical Staff Bylaws were reviewed, the Bylaws indicate, page 18 "b. Pre-operative Requirements," under section iii. "1. Current History and Physical can be defined as completed within the last thirty (30) days, which if used must contain an update unless the procedure is done under a Physician documented Emergency situation".

Based on interview with nursing staff interview and interview with the Risk Manager/ Quality Assurance Officer and clinical record review the facility failed to have a history and physical completed and on the chart within 24 hours of admission for 4 of 30 sampled charts patient #6, #12, 22 and #19.

The findings are:
1. During chart review on 6/25/12 Patient #6 was found not to have a history and physical (H&P) on his chart his admission date was 6/20/12. The registered nurse {RN} "A" was asked to find the history and physical. She could not find in the chart then called dictation to see if it was there which it was not. She then states, " I will call the doctor's office and let them know " .
2. An interview was conducted with the Risk Manager/Quality Assurance Officer on 6/27/12 about 8:45 am. She said she is in the process of using Utilization Review to check charts to make sure history and physicals are in the chart within 24 hours.
3. On 6/27/12 during closed chart review Patient # 19 was found to have a date of admission of 5/15/12. A history and physical is found to have a dictated date of 6/6/12. An interview was conducted with the Risk Manager/Quality Assurance Officer on 6/27/12 about 4:00 pm to find a more current H&P. She confirmed the H&P was not completed within 24 hours of admission for Patient #19.







29722



On 06/26/2012 an open record review was conducted on patient # 22. The patient underwent a non-emergent surgical procedure on 06/25/2012. The record revealed a history and physical (H & P) dated 05/16/2012. The H & P was greater than 30 days and not updated prior to surgery.

The facility's Medical Staff Bylaws were reviewed, the Bylaws indicate, page 18 "b. Pre-operative Requirements," under section iii. "1. Current History and Physical can be defined as completed within the last thirty (30) days, which if used must contain an update unless the procedure is done under a Physician documented Emergency situation


30101


On 6/27/12, a review of the medical record of Patient #12 was conducted. The patient was admitted for a procedure in the OR requiring anesthesia, and there was no history and physical documented in the record. On 6/27/12 at approximately 10:15 am, an interview was conducted with employee E. He was asked if the patient has a History and Physical anywhere on the chart. He stated that she did not.

Based on observation, interview and facility policy review, the hospital failed to ensure that outdates drugs and biological were not available for patient use.

The findings include:

1. On June 25, 2012 at approximately 10:45am, the Surgical Unit's crash cart was inspected. The defribrillator noted on top of the crash cart had expired electrode pads, with an expiration date of 05/2012. This was pointed out to the pre op/post op Registered Nurse (R.N.) assigned to pre and post op. He replaced immediately.

The surgery unit's crash cart emergency drugs were inspected. Found to be expired were:
(5) Adenosine 6mg/2ml vials - expired 03/12
(2) Naloxone Hydrochlorie 2mg/ml injectable prefilled syrings - expired 03/12
(1) Furosemide 100mg/10mg single dose vial - expired 1/April/2012
(5) Amiodarone 150mg/3ml vial - expired 03/2012
(1) Aminophylinne 500mg - 20ml vial - expired June 1, 2012
(4) Epinephrine injectable 1:10,000 Luer-jet 1mg/10ml - expired 03/12
(1) Dextrose 50% injectable 25gm (0.5g/ml) - expired March 1, 2012
(1) Dopamine 400mg - 250ml bag - expired April 2012.

Noted on each crash cart drawer were inspection stickers - the first drawer was dated as being last checked on 08/29/2011, the second drawer sticker dated 02/10/2012 and the third drawer sticker, dated 08/29/2011.

The pre op/post-op registered nurse (R.N.) stated it was the pharmacist's responsibility to check the emergency medications on the crash cart for outdates.
2. On June 25, 2012 at 1:05pm an interview was conducted with the Pharmacist. He stated it was the Pharmacy Consultant's responsible to check the crash cart for expired medications. In the presence of the Pharmacist and the pre op/post op R.N., the medication cart in the pre-op/post-op area was inspected. The following medications were found to be expired:
(2) Calcium Chloride 10% injectable 10 ml with an expiration date of June 1, 2012.
There was also one opened 20 ml single dose vial of Sterile Water.

3. On June 26, 2012 at approximately 09:00am an interview was conducted with the facility's Pharmacy Consultant. He stated, he's not here that much anymore, but he checks every room with controlled drugs, checks the counts. Also states he checks the drugs in the crash cart, but can't remember when it was done last.
A review of the facility's most recent Operative Room (OR) "Medication Area Inspection Checklist", dated 02-10-12 indicates "E. Crash Cart - 2. The crash cart is free of expired medications - noted handwritten are the words 'Ntg Soln removed' with a blank area to follow under the heading of "YES, NO, N/A".
4. On June 26, 2012 at 9:35 am during an interview with the pharmacist and a tour of pharmacy, random medications were checked for outdates. Found to be expired were the following: (1) Acylovir 400mg tablet - expired 03/01/2012; (49) Theophylline 300mg tablets - expired 06/01/2012; (49) Dipyridamole 25mg tablets - expired 06/01/2012; (4) Avandia 4mg tablets - expired 03/12; (14) Anzemet 12.5mg/0.625mg injection - single dose vial - expired 11-2011; (6) bottles Actidose with Sorbital (Activated Charcoal) 120ml - expire 05/2012 and (2) bottles Actidose - Aqua - (Activated Charcoal) suspension 50 gms 240 ml - expired (4) - Avandia 4mg - expired 03/2012.

A review of the facility's most recent Medical Surgery (Med Surg) "Medication Area Inspection Checklist", dated 02-20-12 indicates "E. Crash Cart - 2. The crash cart is free of expired medications"... marked as "Yes". Noted handwritten at the bottom of the form were the words "6 -Removal Tussinex. Exp 10 Ambien 10mg.
A review of the facilitys policy, entitled "Unit Inspections", policy # PH-10, indicates "all drug storage areas within this hospital will be inspected at least monthly by the Pharmacist."




28534

The crash cart on the Medical Surgical unit was viewed on 6/26/12 about 9:10 am with Registered Nurse ( RN) (C). The following medications were found to be expired: Dobutamine 1000 mcg/ml in 5% dextrose 250 milliliter (ml) has an expiration date of 1/12; D50 25 grams (0.5 grams/ml) has an expiration date of 5/12; and two 500 ml bags of Lidocaine 2 grams (4 mg/ml) has expiration dates of 2/12. RN (C) confirmed the medications were expired.

An interview with RN (C) was conducted on 6/26/12 about 9:15 am. He stated the crash cart is checked daily. The defibrillator has a strip run to ensure it is in working order and the labels on the drawers where the medications are kept are checked to see if any medications are about to expire. The drawer does not indicate there are medications ready to expire.





30101

On 6/25/12, at approximately 10:30 am, a tour of the Emergency Department was conducted. Observation of the medication room revealed that the narcotics cabinet contained a vial of Diazepam 5 mg/ml that was opened and there was no date on the vial indicating when it was opened. Inspection of the medication drawers for the non-controlled medications revealed that the following drugs were in the drawers, but were expired: Buspar 15 mg, exp: 04/12; Children's Aspirin Chewable 81 mg, exp: 05/12; Celebrex 200 mg, exp: 04/12; Cetirizine HCL 10 mg, exp: 6/1/12; and Aminophylline 500 mg, 25 mg/ml, exp: 6/1/12.


On 6/25/12, at approximately 11:15 am, a tour of the Intensive Care unit was conducted. Observation of the medication room revealed that the narcotics cabinet contained 2 expired medications: Morphine Sulfate ER 30 mg exp: 03/12 and Dilaudid 2 mg, expired 6/23/12. The medication drawers containing non controlled medications was inspected and it was found that there were 4 medications that were expired, including Propanolol 1 mg/ml, exp 05/12; Diphenoxylate HCL and Atropine 25/0.025 mg, exp: 03/12; Librium 25 mg, exp: 05/12 and Narcan 10 mg injectable, exp: 6/1/12.

On 6/26/12 at approximately 1:30 pm, the medication cart on the Medical Surgical Floor was checked. The narcotics drawer had 1 vial of Diazepam 5 mg/ml that was opened, and there was no date on the vial indicating when it was opened.

Based on observation of reach-in refrigerator, interview with dietary manager, dietician, and dietary staff Employee (B), and record review of dish machine temperature log the facility failed to dispose of expired food, and maintain a functioning dish machine to maintain proper sanitation of dishes.

The findings are:

1. During tour of the kitchen on 6/25/12 about 10:25 am the walk in refrigerator was observed to have a quart carton of Dairy Fresh heavy whipping cream with an expiration date of 6/3/12. A container of Ranch Dressing was also observed in a jug that had aluminum foil as a lid. The date written on the aluminum foil is 5/12/12. The Dietary Director says the dressing has a shelf life of one month. She confirmed both of the above items were expired. She then stated, "We will discard them immediately".

2. During the tour on 6/25/12 the high temperature dish machine was observed to be leaking. There is an aluminum pan underneath a pipe that leaks steadily. During observation of the dishwasher on 6/26/12 the leak is still observed. The dietary aide is washing lunch dishes. The wash cycle was observed to be 170 degrees on the first run and 180 on the second run. The Employee ( B) says the temperature should be 140 to 160 degrees. The rinse cycle was observed to be 158 on the first run and 160 on the second run. The temperature should be 180 to 200 degrees.

3. Employee (B) was questioned about the procedure to follow if the temperature is not correct for the rinse cycle and she said she would let her supervisor know about the temperature. She would then run the same dishes through the machine several times then spray the dishes with bleach solution and allow to air dry.

4. A review of the temperature log for the month of May and June were viewed. The temperature seems to be consistently running around 160 to 170 degrees for both months. The dietary director was asked to provide the policy for sanitation of dishes if the rinse cycle did not reach appropriate temperatures. She stated, "We were told by the state to spray with bleach solution and air dry. I have no written policy to follow".

5. An interview was conducted with the part-time dietician on 6/26/12 about 2:45 pm. She said she is not sure what should be done for proper sanitation of the dishes if the rinse cycle is not appropriate. She then stated, "I think the spray bleach solution is okay if the proper concentration is used. The spray should not be a long term solution".

Based on observation and interview the facility failed to ensure appropriate infection control measures were implemented regarding the storage, ability to track infections and disinfection of gastrointestinal endoscopes and failed to ensure the proper disinfection/cleaning of the blood glucose machine.

The findings include:

On June 25, 2012 at approximately 10:45am a tour of the surgical unit was conducted. In the presence of the Acting Unit Manager, the storage room for the colonoscopes and upper endoscopes was toured. The room not only stored the endoscopes, but was also where the endoscopes were cleaned. The endoscopes were stored in a manner that failed to prevent cross-contamination. The disinfected upper endoscopy scopes were stored within inches of the disinfection solution, which at the time contained a endoscope in the process of being disinfected. The colonoscopes were hung on the wall directly across from the sink where dirty water from cleaning the endoscopes was emptied. The biopsy forceps and snares, failed to be packaged in bags to indicate sterility and hung freely from the wall as well.

The Acting Unit Manager was asked about the storage of the endoscopes and how the scopes are tracked in the event of an infection. The Acting Unit Manager stated they did not have a process in place to track which scope was used on each patient, they would have no way of know which scope was used. The unit failed to maintain a log or issue scope identifiers to track in the event of an infection.

Observed during this observation was a container/bin of Cidex OPA (a solution used for high level scope disinfection). The label on the lid of the container had 2 dates written on tape; June 4 and June 18. When the Acting Unit Manager was asked about the dates on the container, she stated that June 4 was when the solution was mixed and June 18 was the date the solution should be discarded. The solution should have be discarded 7 days ago. The Acting Unit Manager stated they test the solution before use, and proceeded to test the disinfection solution for efficacy. The efficacy was still good. A review of the manufacturer's recommendations, indicated that ...... Cidex OPA..."Manual Processing: ....with an immersion time of at least 12 minutes for a resuse period not to exceed 14 days."

The facility's policy entitled "Scope Cleaning, Rigid and Flexible", dated approved 11-30-00, indicates "3. Take to cleaning area and place in water and betadine scrub solution, brush all channels thoroughly." This practice is no longer performed.





28534








On 6/27/12 about 11:30 am an observation was made of blood sugar monitoring on Patient #22. Licensed Practical Nurse (LPN) D was observed to clean the facility blood glucose meter with alcohol before and after the procedure. An interview was conducted with LPN (D) and she stated, " I do not use anything other than alcohol to clean the meter". At 11:35 an interview was conducted with the Medical Surgical Registered Nurse (RN) Unit Manager. She said, "I clean the meter with alcohol".

The RN unit manager was requested to provide a policy and procedure for use of the meter. The policy was viewed with the unit manager who confirmed that the policy does not indicate what specific agent should be used to clean the meter.

Based on interview and facility record review, the hospital failed to ensure the medical staff performed procedures in which they have been granted privileges to perform. This impacted 2 of 3 physicians in the OR (operating room).

The findings include:

1. On 06/26/2012 at approximately 4:00pm, with the assistance of the Administrative Assistance/Human Resource Supervisor, the medical staff record for Physician #1 was reviewed. The physician, a surgeon was granted privileges by the Medical Staff and Governing Board for Active Privileges in Emergency and General Surgery on 11/30/2011. The Delineation of Surgical Privileges form, filled out by the requesting physician failed to include Colonoscopy and Upper Endoscopic procedures. Physician #1 was not granted privileges to include Colonoscopy and Upper Endoscopic procedures. Noted on the surgery schedules were Colonoscopy and Upper Endoscopic procedure performed by this physician.

On 06/27/2012 the medical staff record for Physician #2 was reviewed. Physician #2 was reappointed and granted active privileges effective July 27, 2011. Physician # 2's delineation of Surgical privileges form, completed by the requesting physician failed to include Colonoscopy and Upper Endoscopic procedures. Physician #2 did not have privileges to perform these procedures. Noted on the surgery schedule, past and present, were Colonscopies and Upper Endoscopies scheduled and performed by Physician #2.

2. On 06/27/2012 at approximately 08:45am an interview was conducted with the preop Registered Nurse (R.N.) responsible for scheduling surgical procedures and assuring that physicians have privileges to perform procedures they are requesting to perform. He stated there is an OR Log Book that indicates the physicians and their privileges, but he has not looked at it. The R.N. did not know that Physician #1 and Physician #2 did not have privileges to perform Colonoscopies or Upper Endoscopies.

3. 06/27/2012 at 09:15am interview conducted with the Risk Manager. She stated that the OR Supervisor is responsible for ensuring the physician has privileges - that they are such a small place that they usually know what the physician can and cannot do. If they were to come across a physician wanting to do something they are not credentialed for it would be brought to the attention of Director of Nurses (DON) or to Administration.

4. On 06/27/2012 at approximately 2:20pm an interview was conducted with the Administrator. He was not aware that Physician #1 and #2 were not given privileges to perform Colonoscopy or Upper Endoscopic Procedures. He felt this was an oversight. Temporary Privileges would be granted right away.

5. The facility's medical staff bylaw were reviewed. The Bylaws indicate page 31, "Article VII, Clinical Privileges... 1. Exercise... a. Every Practitioner providing Clinical Services at the Facility, except as expressly provided in these Bylaws, will be entitled only those privileges specifically granted to him/her by the Board."

Based on interview and facility record review, the facility's surgical services policies and procedure failed to be accessible to staff and failed to assure achievement and maintenance of high standard of medical practice and patient care.

The finding include:

06/25/2012 @ 2:30pm interview conducted with pre-op/post-op nurse. He stated that the only policies he was aware of were the policies that were in the 1 inch binder in the recovery area. The policies failed to address Emergencies in the OR, Fire Safety, Shelf Life of sterile supplies, Prepping the Surgical Patient, Positioning of the Patient and other policies pertinent to the care of the surgical patient.

The policies requested for review were not readily available to the survey team. Many policies such as, policies related to Verification of surgery site and Fire Safety in the OR, were dated as being approved November 2011 and had remained in the Director of Nurse's office since then and not available to staff.

Several policies had the heading of Walton Regional Hospital, dated 1989, including the policy for Malignant Hyperthermia.

The policy for verification of correct site surgery, includes a "Time Out Checklist for Surgical Procedures." This checklist, however is not currently in use.

On 06/27/2012 at approximately 2:10p an interview was coducted with the (Director of Nursing) DON, who stated that some of the policies that are being requested have been worked on, but have not made it to the board as of yet. The policies related to Fire Safety and Verification of Correct Site Surgery are dated 11/2011. These policies were not in the policy and procedure book as the Risk Manager has had these policies at her desk since November 2011 (7 months).

A review of the policy and procedure book failed to have policies that addressed aseptic and sterile surveillance and practice (shelf life of sterile packaged items), including scrub techniques; identification of infected and non-infected cases, Patient care requirements related to patient consents and releases, clinical procedures and safety practices including surgical patient positioning. Duties of the scrub and circulating nurse. Personnel policies unique to the Operating Room. Resuscitative techniques, including Do Not Resuscitate (DNR) status. Care of the surgical specimens. Appropriate protocols for all surgical procedures performed (procedure specific), sterilization and disinfection (including flash sterilization), outpatient surgery post-operative care planning and coordination, and provision for follow-up care.

Based on interview with Employee E and review of the medical record of 2 patients in the OR, (Patients #12 and #14) (out of a sample of 30 total patients) the facility failed to ensure that there was a current and signed History and Physical on 1 of 2 of the records reviewed.


Findings:

1)On 6/27/12, a review of the medical record of Patient #12 was conducted. The patient was admitted for a procedure in the OR requiring anesthesia, and there was no history and physical documented in the record. On 6/27/12 at approximately 10:15 am, an interview was conducted with employee E. He was asked if the patient has a History and Physical anywhere on the chart. He stated that she did not.










29722


On 06/26/2012 an open record review was conducted on patient # 22. The patient underwent a non-emergent surgical procedure on 06/25/2012. The record revealed a history and physical (H & P) dated 05/16/2012. The H & P was greater than 30 days and not updated prior to surgery.

The facility's Medical Staff Bylaws were reviewed, the Bylaws indicate, page 18 "b. Pre-operative Requirements," under section iii. "1. Current History and Physical can be defined as completed within the last thirty (30) days, which if used must contain an update unless the procedure is done under a Physician documented Emergency situation".

Based on interviews with the Chief Operating Officer (COO)/Administrator and the Risk Manager/Quality Assurance (QA) officer, and review of the by laws, the facility failed to assure that the Certified Registered Nurse Anesthetist (CRNA) has current privileges to practice at the hospital.

Findings:

1) On 6/28/12, at approximately 1:00 pm, an interview was conducted with the Risk Manager/QA officer. She was asked if she could produce documentation that the CRNA was currently privileged to practice in the hospital. She stated, "no, it's not there".

2) On 6/28/12 at approximately 12:15 pm, review of the personnel file of the CRNA was conducted. Documentation revealed that he was granted temporary privileges upon hire in February, 2011, and per the medical bylaws, temporary privileges are for 2 months. Documentation revealed that his privileges have not been continued since the initial temporary granting, and that he is currently practicing without having privileges to do so.

Based on observation and open patient record review, the facility failed to ensure an accurate anesthesia record for of of 30 patients reviewed (#22).

The findings include:

On 06/25/2012, beginning at approximately 11:25am, the surgical process was observed for patient #22. The patient, upon completion of the surgical procedure at 11:39am, was noted after being extubated to have a low oxygen saturation level. The Certified Registered Nurse Anesthetist (CRNA) promptly insert an oral airway and maintained supplemental oxygen. The patient was observed to have an oxygen saturation level as low as 79. The CRNA continued to manage the patient's airway, using a jaw-thrust technique to open her airway and continue with supplemental oxygen via mask. There were periods where the mask or jaw thrust manuever was lifted and her oxygen saturation would drop. At no time, during this surveyor's observation, did the patient's oxygen saturation get above 90%. The patient had audible stridor (sound heard with partial airway obstruction), this was commented by the CRNA and thought to be related to edema or spasms. The CRNA also had a discussion with the physician about her edema to her face/neck. He also contacted respiratory therapy. The patient was subsequently admitted to ICU for BiPap (positive pressure airway delivery system). The patient was observed until approximately 12:45pm.

On 06/26/2012 an open record review was conducted for patient # 22. The record failed to indicate, during this surveyor's period of observation, the patient's oxygen saturation and condition as witnessed. The CRNA recorded the patient's oxygen saturations during this time at 92% or higher. There was no mention of the patient's facial edema or stridor. The anesthesia record did not reflect what was actually observed.

On 06/27/2012 at approximately 11:55am an interview was conducted with the C.R.N.A. The CRNA was questioned regarding patient #22 during her intra-operative anesthesia period. The CRNA stated her oxygen level got above 90% - he recorded her oxygen as 92% or higher. The CRNA did recall our discussion of her stridor, but there is no documentation to support this in the record. The CRNA stated he charted after the fact. The CRNA confirmed in the presence two additional surveyors that the patient had stridor and edema, - however there is no document to support either in his intra-operative anesthesia record.