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Based on medical record review, policy and procedure review and interview, surgical staff did not document a complete pre and intraprocedural assessment for Patient #1 in accordance with physician orders and facility policy and procedure.

Findings include:

Review of Patient #1 medical record dated 03/15/2021 revealed the patient underwent an esophagogastroduodenoscopy (EGD) for bariatric preoperative assessment under monitored anesthesia care (MAC).

Review of Patient #1 physician orders dated 03/15/2021 at 08:45 AM revealed orders for preop vital signs, pulse oximetry (oxygen saturation) and to notify the physician of a temperature greater than 101 or lower than 95 and a heart rate greater than 120.

Review of Patient #1 flowsheets dated 03/15/2021 revealed pre-procedural vital signs were documented at 08:35 AM as heart rate 121, respirations 20, blood pressure 153/75 and pulse oximetry 95%. Temperature is not documented, the patient's NPO (nothing by mouth) status is not addressed and there is no documentation to indicate the physician was notified of the patient's elevated heart rate.

Interview with Staff (M), Anesthesiologist on 08/26/2021 at 09:15 AM revealed NPO status is assessed by nursing in the pre-procedure area.

Review of Anesthesia Post evaluation dated 03/15/2021 after Patient #1 arrived in the post anesthesia care unit (PACU) revealed the patient had an episode of apnea (temporary cessation of breathing) with low oxygen saturation and bradycardia (low heart rate) requiring treatment with atropine and phenylephrine and converting to ambu assisted ventilation to restore satisfactory blood pressure and oxygen saturation during the procedure.

Review of nursing documentation dated 03/15/2021 revealed no documentation related to Patient #1 apneic episode during the procedure.

Review of policy titled "Guideline for Care of the Patient Undergoing an Invasive Procedure in a Non-OR Procedural Room", revised 06/30/2020, revealed the Registered Nurse (RN) pre-procedure assessment is to be completed and the provider is to be informed of any abnormalities found in the assessment. RN's present during the procedure are to complete documentation that includes the patient tolerance of the procedure.

Interview with Staff (C), Director of Quality and Patient Safety and Staff (E), Significant Event Manager on 08/26/2021 at 09:07 AM verified the above findings.

Based on medical record review, policy review and interview, patient history and physical (H&P) was not documented no more than 30 days before or updated in accordance with facility policy for 4 of 22 patients undergoing endoscopic procedures (Patient # 1, 6, 10 and 12).

Findings include:

Review of Medical Staff Bylaws revealed an updated assessment of the patient must be completed and documented in the medical record within 24 hours of admission or before surgery, or before a procedure requiring anesthesia services for patients whose history and physical was completed prior to admission.

Review of facility policy titled "Requirement for History and Physical, dated 07/26/2019 revealed patients receiving general anesthesia and patients undergoing a local procedure under moderate sedation will have a limited history and physical completed.

Review of medical records for patients who underwent endoscopy procedures on 03/15/2021 revealed Patient #1 and 6 had a H&P dated 02/11/2021 with no update documented, Patient #10 H&P was dated 12/01/2020 with no update documented and Patient #12 did not have a H&P.

Interview with Staff (E), Significant Event Manager and Staff (A), Quality Patient Safety on 08/27/2021 verified the above findings.

Based on medical record review, policy review and interview, the post anesthesia care unit (PACU) nursing staff did not document ongoing assessment of Patient #1.

Findings include:

Interview with Staff (BB), PACU RN on 08/26/2021 at 10:08 AM revealed on 03/15/2021 after approximately 40 minutes in the PACU, Patient #1 had a breathing pattern change and a rapid response was called.

Review of Post Anesthesia Evaluation note dated 03/15/2021 revealed anesthesia was called by staff as Patient #1 was "unresponsive and tachycardic with heart rate up to 160 and unable to get good reading on 12 lead EKG." Non-rebreather on and nasal trumpet airway in. Oxygen saturation 88-90%. Patient unresponsive and appeared to be seizing. Blood pressure 96/?

Review of Nursing Phase II Recovery documentation dated 03/15/2021 revealed vital signs were documented for Patient #1 every 5 minutes from 09:55 AM to 10:40 AM with heart rate between 104 and 106, respirations between 32-35 and oxygen saturation between 90-93%. At 10:50 AM vital signs were documented as heart rate 118, respirations 30 with oxygen saturation 96%. At 11:10 AM heart rate was 128, respirations 32 with oxygen saturation 95%. Narcan 0.4mg (medication to reverse opiates) was administered at 11:11 AM with minimal response. At 11:15 AM blood pressure 151/88, heart rate 129, respirations 30 with oxygen saturation 95%. No further vital signs or patient assessment were documented until 12:13 PM when a rapid response was called. At 12:24 PM heart rate 157, respirations 50 with oxygen saturation 88%. Patient #1 was stabilized and at 12:53 PM was transported to the intensive care unit.

Review of facility policy titled "Rapid Response Team" revealed the criteria for calling a rapid response includes significant change in heart rate, or blood pressure, or respiratory rate, a decrease in oxygen saturation despite oxygen administration. The nurse responsible for the patient in the PACU should be at the bedside and have the medical record available for review and provide a clear summary of the patient status and events that precipitated the calling of the rapid response team.

Telephone interview on 08/31/2021 at 09:29 AM with Staff (E), Significant Event Manager verified the above findings.