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Based on review of 1 of 6 medical records (patient #1), review of Patient Complaint Policy and Procedure (reference #130, effective 6/02/2002, revised 06/2008) review of grievances for 11/2009-2/2010 and staff interviews, the hospital failed to provide a written notice of its decision regarding the steps taken to investigate the grievance voiced by patient #1's mother. Finding:

Review of the medical record (admission form) revealed patient #1 was a 15 year-old, 9th grade student admitted to Monroe Surgical Hospital on 11/23/2009 at 6:00 AM with diagnosis of impacted teeth and a medical history of "autism". Review of the "Register of Operations" log (where the scheduler documents the initial date, time and type of surgery) revealed patient #1 was scheduled for the removal of 8 bony impacted teeth and extraction of 4 teeth on 11/23/2009. The Pre-admission form indicated patient #1 was "autistic (and) easily agitated. He does real well with people. Usually happy child". Review of the 11/23/2009 physician orders (the only documentation by a physician in regards to the patient) revealed S11 (board certified oral surgeon) was the attending physician.

Review of the 11/23/2009 ASU (Ambulatory Surgery Unit) record revealed at 6:00 AM patient #1 was accompanied by his parents on admission to the unit. Further review revealed S5RN documented patient #1 was ambulatory, oriented to the unit and waiting room, his level of consciousness was alert, responsive, oriented and his psychosocial status was calm. Further review of the ASU record revealed at 7:00 AM on 11/23/2009 S5RN documented "case cx (cancelled) per Dr. (S9 anesthesiologist)".

Review of the 11/23/2009 surgery schedule revealed a line was drawn through the entry for patient #1. Review of the medical record revealed no documented evidence that S9 or S10 (oral surgeon) gave an order for patient #1's surgery to be cancelled or an order for the patient to be discharged from the hospital. Review of the Medical Staff Rules and Regulations (adopted 1/17/2005) revealed "a patient may be admitted and discharged only on order of the attending practitioners".

Review of the 11/23/2009 grievance voiced by patient #1's mother and documented by S3, the administrator at Monroe Surgical Hospital revealed "mother (patient #1's mother) called to complain that her son's surgery was cancelled after being scheduled for 3 weeks due to a lack of equipment. According to the mother, Dr. S10 told her that MSH (Monroe Surgical Hospital) would not do her son's surgery due to a lack of equipment and that she needed to 'take her son where they do (severely retarded children)'. Apologies were extended to (patient #1's mother) and her son. (Patient #1's mother) stated her son was autistic and well behaved."

The grievance further indicated that on 11/24/2009 (no time documented) S3 "spoke with mother (patient #1's mother), to let her know the Anesthesiologist (S9) was not comfortable in doing her son's case. She asked if our facility treated (severely retarded) patients and I explained that for confidentiality reasons I could not discuss treatment of any patient with her, she voiced she understood. I again apologized for the regrettable inconvenience caused to her and her son. I also let her know that I expedited the return of the deposit made on the account and the refund was mailed. She thanked me and asked for the name of the Anesthesiologist."

Review of the the investigation section of the 11/24/2009 report by S3 administrator revealed "Dr. (S9) stated the ASU nurse called him at home requesting sedation for a 15 y/o (year-old) autistic child to place an IV prior to surgery. Dr. (S9) said he was not comfortable giving such an order without any history or knowledge of the patient. Dr. (S9) said when he got to the hospital that the child was agitated loud, disrupting the other patients in the unit and the staff had moved the child to a more private area in the unit. Dr. (S9) then proceeded to review the child's H&P (History and Physical) and it was not available on the chart. Dr. (S9) stated the child's surgeon was in the unit and he voiced concern to the child's surgeon, Dr. (S10), that he was not comfortable in doing the child's surgery at MSH (Monroe Surgical Hospital. Dr (S9) stated he told the surgeon that he would go and speak to the mother and explain his concerns, but the surgeon said he would speak to the mother and schedule the surgical case elsewhere."

Further review of the grievance revealed the administrator "talked with the nurse, (S5 RN), preparing the child for surgery. She stated she called Dr. (S9) requesting sedation to place an IV. She described the child as agitated, loud, and running in the unit. She stated there was 'no way she was going to be able to get an IV into the child'. She stated Dr. (S9) would not give a phone order for the patient, that he stated he did not know any history about this patient".

There failed to be documented evidence that the hospital conducted a thorough investigation of the grievance by not interviewing patient #1's surgeon, Dr. S10. There failed to be documented evidence that Monroe Surgical Hospital sent a written response to patient #1's mother informing her of the steps taken by the hospital in order to investigate her grievance. In an interview on 3/16/2010 at 2:00 PM the administrator confirmed that she did not interview Dr. S10 and that the hospital did not send a letter to patient #1's mother after the investigation was complete.

Review of policy "Patient Complaint" (reference #1030, revised 06/08) revealed "any complaints received by telephone will be transferred to the department manager. The risk manager is responsible for following up on all patient complaints and feedback to the patient, department manager and administration. Administration retains final responsibility for the resolution of all patient complaints. A record of the complaint, investigation, follow-up action and response to the patient will be kept using the Patient Complaint Form. S3 Administrator stated during the interview on 3/16/2010 at 2:00 PM that this was the policy she followed for the grievance voiced by patient #1's mother.

Based on review of 1 of 1 medical record of patients whose surgery was cancelled in a total sample of 6 and interviews, the hospital failed to ensure 2 of 6 physicians were accountable to the Governing Body for the quality of medical care provided to patients in accordance with hospital rules and regulations as evidenced by the failure of : 1) Dr. S9 to evaluate patient #1 prior to canceling the patient's surgical procedure, 2) Dr. S10 to evaluate patient #1 to determine if the concerns voiced by Dr. S9, anesthesiologist, were justified and presented an accurate description of patient #1, and 3) Dr. S10 to provide an order to discharge patient #1 from the hospital after the patient was admitted for a surgical procedure and the surgery was cancelled. Findings:

Review of the admission form revealed patient #1 was a 15 year-old, admitted to Monroe Surgical Hospital on 11/23/2009 at 6:00 AM with diagnosis of impacted teeth and a medical history of "autism". Review of the 11/23/2009 surgery schedule revealed patient #1 was scheduled for the removal of 8 bony impacted teeth and extractions of 4 teeth. Review of the the pre-admission form revealed the nurse documented patient #1 was "autistic (and) easily agitated. He does real well with people. Usually happy child".

Review of the 11/23/2009 ASU (Ambulatory Surgery Unit) record revealed at 6:00 AM patient #1 was accompanied by his parents on admission to the unit. Further review revealed S5 RN documented that patient #1 was ambulatory, oriented to the unit, his level of consciousness was alert, responsive, oriented and his psychosocial status was calm. Further review of the ASU record revealed at 7:00 AM on 11/23/2009 S5 RN documented "case cx (cancelled) per Dr S9 (anesthesiologist)". Review of the 11/23/2009 surgery schedule revealed a line was drawn through the entry for patient #1. Review of the medical record revealed no documented evidence that Dr. S9 or Dr. S10 (surgeon) ordered to cancel patient #1's surgery, or ordered to discharge the patient from the hospital.

Review of the Medical Staff Rules and Regulations (adopted 1/17/2005) revealed, "a patient may be admitted and discharged only on order of the attending practitioners". Further review revealed "the attending practitioner shall be responsible for the treatment, prompt completeness, and accuracy of the medical record".

On 3/17/2010 at 11:20 AM an interview was held with Dr. S9 who stated he recalled patient #1 because the nurse in ASU called him at home to ask if he would order medication for a patient whom they couldn't handle and was disrupting other patients. Dr. S9 said he did not recall his exact words to the nurse, but basically he told the nurse "No, I would not order medication for a patient I had never seen". Dr. S9 stated when he arrived at the hospital, he reviewed patient #1's medical record and it did not contain any information about the patient's medical history. Dr. S9 further stated that he did not see the patient to evaluate him for anesthesia. Dr. S9 stated when the surgeon (Dr. S10) arrived, he expressed to the doctor that he did not feel comfortable doing the case. During the interview Dr. S9 stated he did not say to Dr. S10 that he was cancelling patient #1's surgery; he just expressed his concerns to the doctor.

Dr. S9 stated as far as the lack of documentation in patient #1's medical record, he never got far enough to document anything in the record and did not understand why the nurses documented he cancelled patient #1's surgery because it is always up to the surgeon to cancel the case. He stated, "I don't cancel surgeries, the surgeon does".

On 3/17/2010 at 10:10 AM a telephone interview was conducted with Dr. S10 who confirmed he was familiar with patient #1. S10 said the patient is autistic with the type in which the patient is very mobile and verbal communication is affected. Dr. S10 stated patient #1 had a constant movement while in his office which made it difficult to exam him. Dr. S10 said he did not know he should have documented in the medical record an evaluation for patient #1 or an account of the events leading to the surgery cancellation. He further stated that he did not know that he was to write or give a discharge order for the patient.

On 3/16/2010 at 2:00 PM S3 Administrator confirmed the medical record for patient #1 did not contain documentation describing patient #1's actions which resulted in surgery cancellation, a physician evaluation for patient #1, a discharge order, or any physician documentation except the admit orders. S3 said during her interview with Dr. S9 he told her that he never saw patient #1 but did discuss the patient with the surgeon and expressed to the surgeon that he did not feel comfortable doing the surgery case at Monroe Surgical Hospital. S3 said S9 told her, "I didn't feel comfortable sleeping the patient".

Based on review of 1 of 6 medical records and interviews, the hospital failed to ensure the RN (registered nurse) evaluated the nursing care for patient #1 who was admitted to the hospital for a surgical procedure and the surgery was cancelled as evidenced by: 1) the failure of the RN to document in the medical record a description and evaluation of patient #1 actions which ultimately led to surgery cancellation and 2) the failure of the RN to obtain a physician order to discharge the patient. Findings:

Review of the closed medical record for patient #1 revealed information on the admission form indicated patient #1 was a 15 year-old, who was admitted on 11/23/2009 at 6:00 AM for removal of impacted teeth and a medical history of "autism". The pre-operative admission forms revealed patient #1 was "autistic (and) easily agitated. He does real well with people. Usually happy child".

Review of the ASU record revealed at 7:00 AM on 11/23/2009 S5RN documented "case cx (cancelled) per (S9 anesthesiologist)". This was the only documentation in the nurses notes regarding patient #1. Review of the 11/23/2009 surgery schedule revealed a line was drawn through the entry for patient #1. Review of the medical record revealed no documented evidence that Dr. S9 or Dr. S10 surgeon ordered for patient #1's surgery to be cancelled or ordered the patient's discharge from the hospital.

In an an interview on 3/16/2010 at 2:15 AM S5RN stated when a surgery patient arrives at the unit she completes an assessment form which addresses their height, weight, meds taken that morning, if they have a ride home, allergies, etc. S5 RN stated she recalled patient #1 who was autistic and came to ASU with his mother. S5 said when he arrived, patient #1 "walked around a lot. He would not sit or lie on his bed for vital signs, he was constantly moving, and I had to speak over him to talk with his mom". S5 indicated she could tell she would need to put the patient in a private room (which they use for small children) because patient #1 was loud, would call out and he would repeat words such as "No, No, No". S5 said the mother would say to patient #1 "Let's sit down and let the nurse do her thing and he would sit for a few seconds and then continue pacing" (this contradicted the documentation by S5 RN on the 11/23/2009 ASU form indicating that patient #1 was "calm".

S5RN indicated after approximately 20 minutes she knew she could not control patient #1 long enough to establish an IV site, so S8 RN offered to call Dr. S9 for an order for oral Versed (sedative) because the patient was constantly moving, but the doctor would not order a sedative because he had not seen the patient.

S5 RN said she knew Dr. S9 talked with patient #1's surgeon (Dr. S10) after he arrived at the ASU, but could not recall if he spoke with patient #1's mother. S5 did recall she told the mother that they were cancelling patient #1's surgery. S5 said she could tell the mother was upset by the tone of her voice.

S5RN further stated she did not know why she failed to document in the medical record pertinent facts regarding patient #1's emotional and behavior status or why she did not get a physician order to discharge the patient. S5RN said she was busy and perhaps she "intended on completing the medical record when she got time and then forgot to do it".

Based on record review and interview the hospital failed to ensure medications were prepared and administered in accordance with practitioners orders for 1 of 1 patients (patient #1) in a total sample of 6. Finding:

Review of the admission form revealed patient #1 was a 15 year-old admitted to Monroe Surgical Hospital on 11/23/2009 at 6:00 AM with diagnosis of impacted teeth and a medical history of "autism". Review of the 11/23/2009 physician orders (the only documentation by a physician in regards to the patient) revealed Dr. S10, (board certified oral surgeon) was the attending physician. Further review revealed Dr. S10 ordered Ancef (antibiotic) one gram, and Solumedrol (steroid) 125 mg (milligrams) to be given intravenously when patient #1's IV (intravenous) was initiated.

Review of the preoperative medication section of the 11/23/2009 ASU record revealed S5RN administered Zantac (a proton inhibitor) 150 mg by mouth at 6:20 AM and administered Ancef one Gram IVPB (piggy back) and Solumedrol 125 mg IVP (push). There was no time documented by the nurse as to when she administered the Ancef or the Solumedrol. Review of the medical record failed to reveal an order for the Zantac and further review revealed there was no documented evidence that an IV was ever started on patient #1 in order to administer the Ancef and Solumedrol. In an interview on 3/16/2010 at 3:35 PM S5RN confirmed that she administered Zantac 150mg by mouth on 11/23/2009 at 6:20 AM but denied giving the Ancef or the Solumedrol.