HospitalInspections.org

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Based on interview, and document review, and review of the Medical Staff Bylaws, the hospital failed to ensure staff recorded a complete history and physical (H&P) in the patient's medical record prior to an invasive operative procedure requiring anesthesia for 4 of 6 patients reviewed (Patients #502, #505, #506, and #903).

Failure to ensure that information required for clinical decision-making was readily accessible to all providers caring for the patient risks poor health outcomes due to unknown or known co-morbid conditions.

Findings included:

1. Document review of the hospital's document titled, "Medical Staff Bylaws," revised 11/2013, showed that the patient's physician must document the history and physical in the medical record before an operative or other high-risk procedure is performed. The minimum content for history and physicals included:

a. Chief Complaint.

b. History of Present Illness.

c. Relevant Past Medical and Surgical History.

d. Current Medications.

e. Allergies or Adverse Drug Reactions.

f. Psychological History.

g. Assessment of Body Systems including the lungs.

2. On 12/03/20 at 10:35 AM, Investigator #5, Investigator #7, the Chief Quality Officer (Staff #501), and the Manager of Peri-Operative and Post-Operative Services (Staff #502) reviewed the medical record for Patient #502. The document review showed the provider (Staff #503) failed to document a complete history and physical that included the patient's current medications as directed by hospital policy.

3. At the time of the observation, Staff #501 and #502 verified the finding and stated that the provider should have assessed and documented the patient's current medication as part of a complete history and physical prior to surgery.

4. On 12/03/20 at 11:00 AM, Investigator #5, Investigator #9, and Staff #901 reviewed the post-operative chart for patient (Patient #903). The patient's chart contained an abbreviated short form H&P that contained a list of medications including ciprofloxacin (an antibiotic), dexamethasone (a corticosteroid that prevents the release of substances in the body that cause inflammation), ibuprofen (an anti-inflammatory medication) and penicillin. A line was drawn through all medications. There was no documentation regarding the crossed off medications, who had crossed the medications off, or why the medications where crossed off. There was no further documentation of patient medications on the history and physical document. Document review of the patient's discharge medication list showed the patient's current medications included albuterol and ibuprofen.

5. At the time of the review, Staff #901 verified the finding and further reviewed the medical record. She was unable to find supplemental documentation of who revised the medical record. Staff #901 reported that documenting the patient's current medications is required as part of the history and physical prior to receiving surgical services.

6. On 12/03/20 at 4:15 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #505. The review showed the provider failed to document a completed history and physical that included a review of the patient's airway/lungs.

7. At the time of the observation, Staff #501 verified the findings and stated that an airway assessment is required as part of a complete history and physical.

8. On 12/03/20 at 4:30 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #506. The review showed the provider failed to document a completed history and physical that included the patient's current medications as directed by hospital policy.

9. At the time of the observation, Staff #501 verified the finding, further reviewed the medical record and was unable to locate evidence of the patients' current medication list.

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Based on interview, document review, and review of the hospital's Medical Staff Bylaws, the hospital failed to ensure that the post-operative surgical notes were completed, and including all required elements as directed by the Medical Staff Bylaws in 4 of the 6 patient charts reviewed (Patient #505, #506, #901, and #904).

Failure to ensure that information required for clinical decision-making was readily accessible to all providers caring for the patient's postoperatively risks patient safety and clinical care following surgery.

Findings included:

1. Document review of the hospital's document titled, "Medical Staff Bylaws," revised 11/2013, showed:

a. Immediately upon completion of the operative or other high-risk procedure, and before the patient is transferred to the next level of care, the patient's physician must complete a brief operative procedural note or a full operative report in the medical record.

b. The brief operative report must include ...estimated blood loss.

c. If a brief operative report is documented, then the full post-operative report must be completed in the medical record within 24 hours after the procedure.

2. On 12/03/20 at 10:10 AM, Investigator #9 and the Manager of Pre-Operative and Post-Operative Care (Staff #901) reviewed post-operative medical record for patient (Patient #901). The review showed the surgeon failed to document a post-operative note prior to the transfer to the next level of care.

3. At the time of the review, Staff #901 verified the missing documentation and stated that the hospital's policy is that the brief post-operative note should be in the patient's chart immediately following the procedure, and the full operative report should be in the patient's chart within 24 hours.

4. On 12/03/20 at 4:15 PM, Investigator #9 and Progressive Care (PCU) Nurse (Staff #902) reviewed a current inpatient post-operative medical record for patient (Patient #904). The patient underwent a surgical procedure on 12/02/20. Investigator #9 found no evidence the surgeon (Staff #505) competed a full post-operative note.

5. At the time of the review, Staff #902 verified that the full post-operative note was not in the patient's chart and stated that the post-operative note should be completed and placed in the patient's medical record within 24 hours post-surgery.

6. On 12/03/20 at 4:15 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the current in-patient medical record for Patient #505. The patient underwent a surgical procedure on 12/02/20. An anesthesia post procedure note showed that anesthesia performed a post-operative assessment on 12/02/20 at 1:21 PM. Investigator #5 found no evidence the surgeon (Staff #505) completed and documented a full post-operative note within 24 hours post-surgery.

7. At the time of the observation, Staff #501 verified the findings and stated that the document might be in transcription.

8. On 12/04/20 at 10:00 AM, Staff #501 provided a copy of the full post-operative notes for Patient #904 and Patient #505. The documents showed that the provider documented the post-operative note for patient #904 on 12/03/20 at 5:41 PM, and documented the full post-operative report for Patient #505 on 12/03/20 at 6:06 PM. Staff #505 verified that the post-operative notes were documented after the investigator findings and stated that the provider was new to the organization and that she would follow up with the provider regarding post-operative note requirements.

9. On 12/03/20 at 4:30 PM, Investigator #5 and the Chief Quality Officer (Staff #501) reviewed the medical record for Patient #506. The review showed the surgeon (Staff #504) failed to document a complete brief post-operative note that included estimated loss.

10. At the time of the observation, Staff #501 verified the finding, and stated that a post-operative note should include estimated blood loss.
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