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Based on review of policies, medical staff bylaws, medical records, and staff interview, it was determined the facility failed to develop and implement a policy that was compliant with requirements related to updating the patient's history and physical (H&P) prior to a procedure or receiving anesthesia for two (#1, #2) of six medical records sampled.

Findings included:

A review of the policy entitled, "History and Physical Requirements," MR.000-08,# , reviewed 07/17 showed there was no requirement for minimum documentation to be on the chart for an invasive procedure that does not involve moderate, deep, or general anesthesia. An H&P will not be required for patients who do not receive any anesthesia. All cases in which an H&P has been performed within 30 days prior to the patient's hospital episode, a legible copy may be used in the patient medical record, provided that in such event an admission update of the H&P, noting any changes in the patient medical record. An update of the H&P must be completed, dated, timed, and signed prior to any operative/invasive procedure, and must be placed in the patient's medical record within 24 hours of admission, but prior to any surgery or procedure requiring anesthesia services.

A review of the facility medical staff bylaws showed the examination and update of the patient's current medical condition must be completed and placed in the patient's medical record within 24 hours after admission, but prior to surgery or procedure requiring anesthesia.

A review of Patient #1's medical record revealed the patient had a cardiac catheterization performed on 04/04/19.

A review of Patient #1's original H&P showed a date of 03/29/19 with an update stamp showing the physician's signature. The physician failed to document the date and time the H&P was updated.

A review of Patient #2's cardiac catheterization report dated 04/04/19 showed the procedure started at 2:33 PM and stopped at 3:09 PM. Documentation showed he patient was out of the cardiac catheterization lab by 3:21 PM.

A review of Patient #2's original H&P showed a date of 03/29/19. The H&P was updated by the physician on 04/04/19 at 3:00 PM, almost 27 minutes after the procedure began and 9 minutes before the end of the procedure.

On 05/28/19 at approximately 2:00 PM, the above medical record findings were confirmed by the Quality Manager.

Based on policy review, medical record review, and staff interview, it was determined the facility failed to implement a policy related to informed consent for anesthesia for two (#1, #6) of six medical records sampled.

Findings included:

A review of the policy entitled, "Moderate Sedation, " #NS.000-15, reviewed 11/18, showed moderate sedation/analgesia (formerly referred to as " conscious sedation " ): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Informed Consent: The physician shall have explained the procedure and sedation/analgesia risks, benefits and alternatives to the patient, and/or family as appropriate, in advance of the procedure, and in particular, in advance of administration of any sedation medication. A signed informed consent, to include the procedure and sedation shall be obtained.

A review of Patient #1's medical record revealed the patient had a cardiac catheterization performed on 04/04/19 and received moderate conscious sedation with
2 mg of Versed and 50 mcg ' s of Fentanyl. Continued review of the medical record failed to reveal the presence of a consent for anesthesia.

A review of Patient #6's medical record revealed the patient had a cardiac catheterization performed on 05/28/19 at 4:34 PM and received moderate conscious sedation with 1 mg of Versed and 50 mcg ' s of Fentanyl. Continued review of the medical record failed to reveal the presence of a consent for anesthesia.

On 05/28/19 at approximately 2:00 PM, the above medical record findings were confirmed by the Quality Manager.

Based on medical record review and staff interviews, it was determined the facility failed to ensure patient information related to medication allergies and unfavorable reactions was appropriately and accurately placed in the medical record for one (#2) of six medical records reviewed.

Findings included:

A review of Patient #2 's history & physical (H&P) physician documentation dated 03/29/19 showed a list of patient allergies, which included morphine.

A review of Patient #2 's allergies in the facility computer system showed morphine was listed as an allergy on 04/04/19 and was still listed as an allergy on 05/28/19.

A review of the pre-anesthesia evaluation dated 04/04/19 at 1:35 PM showed morphine was listed as an allergy with a documented reaction of "drops blood pressure."

A review of physician orders dated 04/04/19, showed the pain medication morphine was ordered by the anesthesiologist.

A review of the Registered Nurse (RN) pain medication administration record (MAR) dated 04/04/19 at 4:23 PM , showed the RN attempted to administer intravenous (IV) Morphine. The documentation showed the patient refused.

An interview with the Director of Pharmacy on 05/28/19 at 12:35 PM revealed morphine was listed as an allergy and was ordered by the physician. The Director stated that after the profile was reviewed by the Pharmacist and it was decided the reaction to morphine was a side effect and not a true allergy. The Pharmacist stated it was the nurse's decision to administer the medication after the pharmacy had reviewed the morphine allergy and decide it was not really an allergic reaction, but rather a mild side effect. The Pharmacy Director confirmed morphine had not been removed from the allergy list. The CNO was present during the interview and stated the facility did not have a policy that allowed RN's to make decisions about degrees of severity of listed allergies prior to administration of a allergy medication. The CNO confirmed the hospital computer software keeps allergy information on the patient and is updated with each admission.

On 05/28/19 at approximately 2:00 PM, the above medical record findings were confirmed by the Quality Manager.