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Based on record review and interview the facility failed to ensure patients are notified their Advance Directives are not honored with statutes and statements that support the facility's objection in 12 of 24 medical records that have Advance Directives, out of a total of 30 records reviewed (2, 3, 4, 9, 15, 16, 21, 22, 23, 24, 26 and 28). This deficiency directly affects patients #2, 3, 4, 9, 15, 16, 21, 22, 23, 24, 26, and 28 and potentially affects all 122 patients treated at the facility during survey.

Findings include:

Per review of the facility Patient Rights and Responsibilities given to patient upon admission, it states under Rights "Formulate Healthcare advance directives and have hospital staff and physicians comply with theses directives (to the extent of law)."

Per review of facility policy titled Advance Directives, revised 5/6/16, it states under #2 "...Staff and/or anesthesia will explain our policy is to not honor activated advance directives during surgery." The policy does not include a statement of limitation based on conscience that includes: facility or individual conscious objections, state authority that allows the objection, specify which procedures would be included in the conscious objection. This is confirmed in interview with Performance Improvement staff S on 4/5/17 at 8:30 AM, who was unaware of the requirements to not honor Advance Directives.

Per Patient #2's medical record review on 4/4/17 at 9:10 AM revealed Patient #2 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure for a right hip replacement, is signed by the patient on 10/20/16. There are two statements on the consent "If I have 'do not resuscitate' (DNR) wishes, they will be put on hold during the procedure. If I have 'do not resuscitate' (DNR) wishes, they will NOT be put on hold during the procedure." There is "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #3's medical record review on 4/4/17 at 9:40 AM revealed Patient #3 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure for a left knee replacement, is signed by the patient on 11/10/16. There are two statements on the consent "If I have 'do not resuscitate' (DNR) wishes, they will be put on hold during the procedure. If I have 'do not resuscitate' (DNR) wishes, they will NOT be put on hold during the procedure." There is "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #4's medical record review on 4/4/17 at 10:00 AM revealed Patient #4 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure for a hysterectomy, is signed by the patient on 12/2/16. There are two statements on the consent "If I have 'do not resuscitate' (DNR) wishes, they will be put on hold during the procedure. If I have 'do not resuscitate' (DNR) wishes, they will NOT be put on hold during the procedure." There is "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #9's medical record review on 4/4/17 at 11:03 AM revealed Patient #9 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure for eye lid surgery, is signed by the patient on 3/27/17. There are two statements on the consent "If I have 'do not resuscitate' (DNR) wishes, they will be put on hold during the procedure. If I have 'do not resuscitate' (DNR) wishes, they will NOT be put on hold during the procedure." There is "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

The above deficiencies were confirmed in interview with Meditech Systems Manager M and Registered Nurse N during record reviews on 4/4/17 between 9:10 AM and 11:03 AM.


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A medical record review was conducted on Patient #15's closed surgical record on 4/5/2017 at 9:52 AM accompanied by Meditech Manager M, Social Worker NN, and Registered Nurse N who confirmed the following per interview:
Patient #15 has an Advanced Directive on file. On Patient #15's informed consent form NA (not applicable) is written through both choices of DNR (do not resuscitate)-whether any DNR wishes would or would not be upheld.

A medical record review was conducted on Patient #16's closed surgical record on 4/5/2017 at 10:20 AM accompanied by Meditech Manager M, Social Worker NN, and Registered Nurse N who confirmed the following per interview:

Patient #16 has an Advanced Directive however it is not on file. On Patient #16's informed consent form NA is written through both choices of DNR whether any DNR wishes would or would not be upheld.


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Per Patient #21's medical record review on 4/4/17 at 2:30 PM revealed that Patient #21 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure is signed by the patient on 4/3/17. There are two statements on the consent "If I have "do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #22's medical record review on 4/4/17 at 3:05 PM revealed that Patient #22 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure is signed by the patient on 3/31/17. There are two statements on the consent "If I have "do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #23's medical record review on 4/4/17 at 3:40 PM revealed that Patient #23 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure signed by the patient on 4/3/17. There are two statements on the consent "If I have do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #24's medical record review on 4/5/17 at 8:35 AM revealed that Patient #24 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure signed by the patient on 4/3/17. There are two statements on the consent "If I have do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #26's medical record review on 4/5/17 at 9:40 AM revealed that Patient #26 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure is signed by the patient on 10/18/16. There are two statements on the consent "If I have do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

Per Patient #28's medical record review on 4/5/17 at 10:40 AM revealed that Patient #28 has an Advance Directive and it is on file in the Medical Record. The Informed Consent for Surgery or Invasive Procedure is signed by the patient on 9/7/16. There are two statements on the consent "If I have do not resuscitate (DNR) wishes, they will be put on hold during the procedure. If I have do not resuscitate (DNR) wishes, they will NOT be put on hold during the procedure." There is a "N/A" written in front of the statements with no signature or initial as to who wrote N/A. The consent does not mention the facility does not honor Advance Directives.

The above deficiencies were reviewed on 4/4/17 between 2:30 PM and 3:40 PM and 4/5/17 at 8:35 AM-11:30 AM during the time of the record reviews with Staff Y and Meditech System Manager M who were unaware it was incorrect and "that's how we always do it here".

Based on record review and interview the facility failed to ensure there are action plans with interventions for improvement projects in 1 of 3 improvement projects reviewed (Patient pain control). This deficiency potentially affects all 122 patients treated at the facility during survey.

Findings include:

Per review of the facility's improvement projects on 4/5/17 between 10:00 AM and 11:00 AM, the project for Patient Pain Control has a goal of 78% of patients will report satisfactory controlled pain. Between 3/16 and 2/17 the Patient Pain Control data fluctuated between 84.62% and 68.97% with 1/17 and 2/17 at 74.29% and 70.37% respectively. Per interview with Performance Improvement S, there is no written Action Plan with interventions to support the project and aide in progressing towards improvement.

Based on record review and interview the facility failed to ensure there is documentation of pain after receiving pain medication, in 4 of 30 medical records reviewed (2, 3, 16 and 29). This deficiency directly affects Patients #2, 3, 16 and 29 and potentially affect all 122 patients treated during survey.

Findings include:

Per review of facility policy titled Pain Management, revised 5/6/16, it stated under #3. "Any patient care provider, from any department, that has implemented a pain control mechanism will reassess the patient by unit specific policy."

Patient #2's medical record review on 4/4/17 at 9:10 AM revealed Patient #2 had right hip replacement on 10/20/16. On 10/20/17 at 2:50 PM Patient #2 received Tylenol (pain medication) for a pain rating of 2 out of a scale of 1-10. The Medication Administration Record has the reassessment for pain scheduled for 3:20 PM. The reassessment for results of the pain medication is at 4:03 PM, 43 minutes after the scheduled time. On 10/21/16 at 1:06 AM Patient #2 received Tylenol for a pain rating of 4. There is no reassessment scheduled or completed for the results of the pain medication.

Patient #3's medical record review on 4/4/17 at 9:40 AM revealed Patient #3 had left knee arthroscopy on 11/10 16. On 11/10/17 at 1:47 PM Patient #3 received Fentanyl (pain medication) for a pain rating of 4. The Medication Administration Record does not have a reassessment scheduled and no reassessment is completed for the results of the pain medication.

The above deficiencies were confirmed in interview with Meditech Systems Manager M and Registered Nurse N during record reviews on 4/4/17 between 8:30 AM and 10:00 AM, who said the expectation is to reassess the patient 30 minutes post pain medication in both the Post Anesthesia Care Unit and the Medical/Surgical floor.


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A medical record review was conducted on Patient #16's closed surgical record on 4/5/2017 at 10:20 AM accompanied by Meditech Manager M, Registered Nurse N, and Social Worker NN who confirmed the following per interview: Patient #16 received pain medication at 12:30 AM on 3/29/2017, there is no documented reassessment until 4:45 AM. Patient #16 was again given pain medication at 4:45 AM and there is no documented reassessment by the nurse who gave the medication. At 7:00 AM there is documentation from the next shift indicating the reassessment was missed.


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Patient #29's chart was reviewed on 4/5/17 at 10:40 AM and revealed that on 10/22/16 at 4:58 AM Patient #29 was given 5 mg of Oxycodone (pain reliever) and no reassessment of pain relief was charted until 9:21 AM which is greater than the facility policy of reassessment of pain management interventions 30 minutes after analgesia has been given.

The above deficiencies were confirmed in interview with Staff Y on 4/5/17 at 10:40 AM that the facility expectation is that staff will complete a reassessment of pain relief/management 30 minutes after analgesic is administered.

Based on record review and interview the facility failed to ensure all medical records are complete within 30 days and/or entries are authenticated with a date, time and signature, in 6 of 30 medical records reviewed (2, 3, 4, 13, 15 and 16). This deficiency directly affects patients #2, 3, 4, 13, 15 and 16 and potentially affects all 122 patientS treated at the facility during survey.

Findings include:

Per review of the facility Medical Staff Rules and Regulations, updated 11/10/16, it states under Section II Medical Records, #6. " It is required that the Physician complete medical records within thirty (30) days after discharge..."

Per review of facility policy titled Medical Record Entries and Physician Requirements, revised 2/9/17, it stated under #5. "Every entry in the medical record should be signed, timed and dated by the author (or other licensed Individual Practitioner when applicable) within the specified time frame.

Patient #2's medical record review on 4/4/17 at 9:10 AM revealed Patient #2 was admitted on 10/20/16 for right hip replacement and discharged on 10/21/16. The Discharge Summary dictated on 10/20/16 is signed by the physician on 12/8/16, over 30 days from date of discharge.

Patient #3's medical record review on 4/4/17 at 9:40 AM revealed Patient #3 was admitted on 11/10/16 for a left knee arthroscopy and discharged on 11/12/16. The Discharge Summary dictated on 11/12/16 is signed by the physician on 12/16/16, over 30 days from date of discharge.

Patient #4's medical record review on 4/4/17 at 10:00 AM revealed Patient #4 was admitted on 12/2/16 for a hysterectomy. There is a physician progress note written on 12/4/16 that is not authenticated with a time.

The above deficiencies were confirmed in interview with Meditech Systems Manager M and Registered Nurse N during record reviews on 4/4/17 at 10:00 AM, who agreed notes should be timed, and records should be complete within 30 days of discharge.


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A medical record review was conducted on Patient #13's closed surgical record on 4/5/2017 at 8:25 AM accompanied by Meditech Manager M, Registered Nurse N and Pharmacist J who confirmed per interview the following: Patient #13 had neck surgery on 3/17/2017 and was discharged on 3/18/2017. There is no documentation regarding who Patient #13 was discharged with. Per interview with Nurse N during the medical record review, Nurse N stated that staff are supposed to document who the patient is discharged to.

A medical record review was conducted on Patient #15's closed surgical record on 4/5/2017 at 9:52 AM accompanied by Meditech Manager M, Registered Nurse N and Social Worker NN who confirmed per interview the following: Patient #15 had bilateral knee surgery on 3/9/2017. Patient #15's family member signed the discharge instruction sheet however there is no documentation regarding who Patient #13 was discharged with.

A medical record review was conducted on Patient #16's closed surgical record on 4/5/2017 at 10:20 AM accompanied by Meditech Manager M, Registered Nurse N, Social Worker NN, and Pharmacist J who confirmed per interview the following: Patient #16 had a revision of a left total knee on 3/27/2017. Patient #16 had general anesthesia provided by an anesthesiologist/certified registered nurse anesthetist. The pre-anesthesia evaluation form has extensive notations written in the body system sections (past history, medical information) by someone other than the anesthesiologist signing the form. This person is not identified on the form.

Based on record review and interview the facility failed to ensure all verbal and telephone orders are authenticated by the physician within 24 hours of being written per facility Medical Staff Rules and Regulations, in 7 of 30 medical records reviewed (1, 2, 4, 11, 13, 25 and 27 ). This deficiency directly affects patients #1, 2 and 4 and potentially affects all 122 patientS treated at the facility during survey.

Findings include:

Per review of the facility Medical Staff Rules and Regulations, updated 11/10/16, it states under Section 7, #2. "All orders for treatment shall be in writing, dated, timed and signed." Regarding telephone orders "The practitioner shall authenticate such orders upon his/her next visit, and within twenty-four (24) hours following the order."

Patient #1's medical record review on 4/4/17 at 8:30 AM revealed Patient #1 was admitted on 10/28/16 for a hysterectomy. On 10/29/16 at 12:50 PM, a telephone order was written for Phenergan for nausea. The order was authenticated by the physician on 11/3/16 at 10:08 AM, more than the 24 hours allowed in the Medical Staff Rules and Regulations.

Patient #2's medical record review on 4/4/17 at 9:10 AM revealed Patient #2 was admitted on 10/20/16 for a right hip replacement. On 10/20/16 at 11:34 AM, a telephone order was written to remove a urinary catheter. The order was authenticated by the physician on 10/27/16 at 8:52 AM, more than the 24 hours allowed in the Medical Staff Rules and Regulations.

Patient #4's medical record review on 4/4/17 at 10:00 AM revealed Patient #4 was admitted on 12/2/16 for a hysterectomy. On 12/2/16 at 11:35 AM, a telephone order was written for Heparin for preventing blood clots. The order was authenticated by the physician on 12/15/16 at 4:33 PM, more than the 24 hours allowed in the Medical Staff Rules and Regulations.

The above deficiencies were confirmed in interview with Meditech Systems Manager M and Registered Nurse N during record reviews on 4/4/17 between 8:30 AM and 10:00 AM, who agreed all telephone orders should be authenticated by the physician within 24 hours.



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A medical record review was conducted on Patient #11's closed surgical record on 4/4/2017 at 1:11 PM accompanied by Registered Nurse N and Meditech Nurse X who confirmed the following per interview: Patient #11 had abdominal and breast surgery on 3/2/2017 and was discharged on 3/4/2017. There are 9 telephone/verbal orders that are not signed within 24 hours. Per interview with Nurse N at the time of the medical record review regarding the time frame for providers to sign orders, Nurse N stated, "They have to be signed within 24 hours."

A medical record review was conducted on Patient #13's closed surgical record on 4/5/2017 at 8:25 AM accompanied by Registered Nurse N, Meditech Manager M and Pharmacist J who confirmed the following per interview: Patient #13 had neck surgery on 3/17/2017 and was discharged on 3/18/2017. Patient #13 had 1 telephone/verbal order not signed within 24 hours.


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Patient #25's medical record was reviewed on 4/4/17 at 2:00 PM revealed that on 10/7/16 at 7:52 PM a verbal order was written for Levaquin (antibiotic) intravenously and the order was not authenticated by ordering physician until 10/9/16 at 8:31 AM which is greater than 24 hours between writing the verbal order and authentication. On 10/9/16 at 1:45 PM a verbal order was written for Glucophage (oral hypoglycemic) and the order was not authenticated by ordering physician until 10/21/16 at 6:13 PM which is greater than 24 hours between writing the verbal order and authentication. A verbal order was written on 10/9/16 at 1:47 PM for Dilaudid (oral analgesic), and the verbal order was not authenticated by ordering physician until on 10/21/16 at 6:13 PM which is greater than 24 hours between writing the verbal order and authentication. A verbal order was written to discontinue urinary catheter on 3/31/17 at 11:25 AM and the order was not authenticated by ordering physician until 4/3/17 at 6:04 PM which is greater than 24 hours between writing the verbal order and authentication.

Patient # 27's medical record was reviewed on 4/4/17 at 2:40 PM revealed that on 10/18/16 at 12:01 PM a verbal order was written for Oxycontin (oral analgesic) and order was not authenticated by ordering physician until 10/24/17 at 7:36 AM.

The above deficiency was confirmed in interview on 4/4/17 at 2:00 PM with Staff Y and Meditech Systems Manager M at time of record reviews who both stated that ordering physician is expected to authenticate verbal orders within 24 hours of giving them.

Based on observation, policy review, and interview the facility failed to ensure staff follow proper food labeling procedures when opening and storing food in 2 out of 2 cold storage areas and that food scoops for dry goods are kept covered and protected area. This deficiency has the potential to affect all patients receiving nutrition from the dietary department during this survey.

The facility training entitled "Labeling and Date Marking" dated for February 2017 for all dietary staff was reviewed on 4/4/17 at 11:15 AM. This document states (page 1) "You must be able to tell when food was stored and by what date it must be used. This means correctly labeling food as it is stored." The document continues on to say "Ready to eat TCS food must be marked if it will be held for longer thaN 24 hours. The mark must indicate when the food must be sold, eaten or thrown out. All food not stored in its original container must be labeled. The count begins on the day the food was prepared or opened. Label must include: Name of the food, Date it was prepared, Use by or discard date and Employee's initials."

On 4/3/17 at 10:55 AM a small free standing refrigerator was observed in the kitchen with various trays of food in it. Each tray contained a different type of food item or beverage. One tray had 4 small bowls of lettuce were individually covered with plastic wrap with a yellow "sticky" note on the front of the tray with a date of "4/1" on it. Another tray was below that with 3 small bowls of cottage cheese and 3 bowls of coleslaw each individually wrapped with plastic wrap and a yellow "sticky" note on the front of the tray with a date of "4/1" on it. The walk in cooler had 4 items containing completed labels, the remainder of opened foods had a preprinted label on them but were filled out with date of opening and type of food with the "product use by" and "initials" not completed.

The facility "Sanitation QA Checklist" was reviewed on 4/4/17 at 11:15 AM which is completed by facility dietician dated 8/25/16 item #2 under "Cold Food Storage Areas" states "Chicken-cubed, breast and steaks-no label with product name, pull date or use by date. Taco-meat has prep date, no product name or pull and use by date in the refrigerator."

The above deficiencies were confirmed in interview with Dietary Manager A on 4/3/17 at 10:45 AM who stated that expiration dates should be on label when food is opened and stored.

The facility policy entitled "Non-Perishable Storage:" was reviewed on 4/4/17 at 11:15 AM. Item #12 states "Scoops are to be used for flour, sugar, cereals, dried vegetables and spices. Scoops are not to be stored in the food containers, but are kept covered in a protected area near the containers."

On 4/3/17 observed in kitchen that 2 uncovered scoops were hanging by S hooks on the front of dry goods container in a traffic area that could be easily touched by legs/feet of staff walking by or carts and supplies as staff pass by.

The above deficiency was confirmed in interview with Dietary Manager A on 4/3/17 at 10:35 AM who stated that it is possible for scoops to be getting contaminated hanging where they are.

Based on record review, observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

42 CFR 482.41- Condition of Participation: Physical Environment was NOT MET.
42 CFR 482.41(b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K- 0351 - Sprinkler System - Installation - - Bld: 02
K- 0712 - Fire Drills - - Bld: 02

Based on record review, observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire, that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET
42 CFR 482.41(b) Standard: Life safety from fire was NOT MET
NFPA 101 (2012 edition) - Life Safety Code was NOT MET

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K- 0351 - Sprinkler System - Installation - - Bld: 02
K- 0712 - Fire Drills - - Bld: 02

Based on observation, record review and interview the facility failed to ensure there is a comprehensive infection control program that includes surveillance to prevent the potential of contamination and/or cross contamination, in 1 of 1 staff observed (I, Z, BB, DD, EE, FF, GG, HH, II, JJ, KK, OO and RR). This deficiency directly affects Patients #21 and 35 and potentially affects all 122 patients treated at the facility during survey.

Findings include:

Per interview with Chief Nursing Officer E on 4/4/2017 at 8:28 AM, regarding the standards of practice followed by surgical services, Nurse E stated that the facility follows AORN (Association of periOperative Registered Nurses), AAMI (Association for Advancement of Medical Instrumentation), CDC (Centers for Disease Control), and APIC (Association of Professionals for Infection Control and Epidemiology.

APIC Text of Infection Control and Epidemiology, Volume 3, edition 4, page 108, Laboratory Services, "Protective laboratory coats, gowns, smocks, or uniforms designated for laboratory use must be worn while working with hazardous materials. Remove protective clothing before leaving for non-laboratory areas (e.g., cafeteria, library, administrative offices)."

AORN Guidelines 2017 Recommendation "VII Sterile fields should be constantly monitored. The sterile field is subject to unrecognized contamination by personnel, vectors (e.g. insects), or breaks in sterile technique if left unobserved. VII.a. Once created, a sterile field should not be left unattended until the operative or other invasive procedure is completed. III.c.2. The surgical gown back should be considered unsterile. The back of the gown cannot be constantly monitored."

Also stated in AORN, "Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair...The benefit of covering the head, ears, and hair is the reduction of the patient's exposure to potentially pathogenic microorganisms from the perioperative team member's head, hair, ears, and facial hair." "III.a. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn."

The facility's policy titled, "Hand Hygiene," #07.01.01, dated May 6, 2016, was received on 4/5/2017 at 11:50 AM. The policy states in part, "Indications for Hand Hygiene A. Before touching a patient, B. Immediately before performing a clean/aseptic procedure, C. Immediately after an exposure risk to body fluids (and after glove removal), D. After touching a patient and his/her immediate surroundings, when leaving the patient's side, E. After touching any object or furniture in the patient's immediate surroundings."

Facility policy entitled "ENVIRONMENT OF CARE-Personal Protective Equipment-Gloves" dated November 26, 2001 was reviewed on 4/4/17 at 12:30 PM item C states "Gloves will be changed after contact with each patient. Change gloves when performing procedures from one body site to another on the same patient." Lippincott Procedures entitled "Surgical wound dressing application", page 2 under "Removing the dressing" bullet point 8 states "Discard the dressing and your gloves in an appropriate receptacle" under "Caring for the wound" states "-perform hand hygiene, -put on gloves, -apply fresh dressing, -remove and discard your gloves, and perform hand hygiene."

Per interview with RN Manager D on 4/4/17 at 11:45 AM facility does not have a policy for administering intravenous medications but that facility staff are to access Lippincott standards.

Lippincott standards entitled "IV Bolus Injection" revised April 15, 2016 provided by RN Manager D was reviewed on 4/4/17 at 12:30 PM. Page 2 bullet point 18 states "Put on gloves".

Per interview with Laboratory Manager KK on 4/5/17 at 11:00 AM there is no policy on lab coats, and the facility does follow APIC standards.

Observations during Blood Draw:

On 4/5/2017 at 7:40 AM, Laboratory Manager KK was observed performing a blood draw on Patient #34. With gloved hands, after obtaining the blood sample, Manager KK obtained the tape dispenser from the laboratory tray, laid the dispenser on Patient #34's blanket, handled the dispenser with contaminated gloves, and after retrieving tape from it put the dispenser back in the tray without cleaning it.

This observation was discussed per interview with Performance Improvement Director S on 4/5/2017 at 11:50 PM who stated, "No, it (the tape dispenser) should have been cleaned before putting it back in the tray."

Per observation on 4/5/17 at 10:20 AM, Phlebotomist OO performed a blood draw on Patient #35 prior to his/her right knee replacement surgery. Phlebotomist OO entered Patient #35's preoperative bay, and placed the lab tray containing blood draw supplies on the floor. Once the blood draw was completed, Phlebotomist OO returned to the laboratory and placed the lab tray on the supply cart. Phlebotomist OO did not don a lab coat to go to the patient do a blood draw, and did not don a lab coat upon entering the lab.

These deficiencies were discussed with Phlebotomist OO and Manager KK on 4/5/17 at 10:30 AM. In response to a question why the lab tray was placed on the floor, Phlebotomist OO said "I don't want to put it on patient surfaces". Manager KK responded "I put the tray on the patient chair, not floor", adding there is no policy where to put the tray, and would not expect it on the floor.


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Observations in Pre-Operative Care Unit, Same Day :

On 4/4/2017 at 7:25 AM the following observations of Registered Nurse Z starting an intravenous access for Patient #31 were made:
Registered Nurse Z was observed walking through the hallway with a glove on Z's right hand. Registered Nurse Z entered Patient #31's bay without removing the glove from the right hand or performing hand hygiene. With this same gloved hand Nurse Z cleansed Patient #31's left hand for the intravenous access, then applied a glove to Z's left hand, no hand hygiene. After inserting the intravenous, Nurse Z removed gloves, did not perform hand hygiene, and left the bay to obtain more tape. Upon return to Patient#31's bay, Nurse Z continued to tape the intravenous, did not perform hand hygiene, donned new gloves to remove trash, put items in Z's pocket, used a pen to document and then put the pen in Z's pocket, and left the bay prior to removing gloves and then performing hand hygiene. These observations were discussed with and confirmed per interview with Chief Nursing Officer, Nurse E on 4/4/2017 at 9:50 AM. Nurse E stated, "I noticed that [Z] had that glove on and already talked to the manager. We can't be doing that."

On 4/4/2017 between 8:00 AM and 8:22 AM the following observations were made for Patient #32's spinal pain injection:
Surgical Technician GG set up a sterile field with the medications and needles that would be needed by Doctor AA for Patient #32's spinal injection. Surgical Technician GG then left the room leaving the sterile field unattended.
At 8:14 AM Registered Nurse JJ gave Patient #32 two intravenous medications without having gloved hands.
At 8:22 AM Doctor AA concluded the procedure, removed gloves and surgical mask and left the room without performing hand hygiene.

These observations were discussed with and confirmed per interview with Chief Nursing Officer, Nurse E on 4/4/2017 at 9:50 AM. In regards to standards of practice for the same day stay area versus the operating room/surgical suite, Nurse E stated, "Yes, we follow AORN (Association of peri-Operative Registered Nurses) guidelines in same day too. You don't leave the table unattended." In another interview on 4/4/2017 at 10:15 AM regarding hand hygiene, Nurse Z stated that everyone is supposed to do hand hygiene after glove removal.

Observations in the Operating Room:

On 4/4/2017 at 9:14 AM an observation of Charge Nurse RR cleaning an operating room was made. Nurse RR was observed removing gloves and exited the operating room into the sterile corridor without performing hand hygiene.

On 4/4/2017 at 9:30 AM Certified Registered Nurse Anesthetist BB was observed setting up intravenous medications for Patient #33's shoulder surgery. Nurse BB failed to cleanse the septum of the first vial accessed (Rocuroniuim). When asked the name of the medication that was accessed, Nurse BB stated, "My opinion is, if it is sterile it doesn't need to be cleaned first...I'll clean it because you are here but I have been doing this for 20 years."
This finding was discussed in an interview with Anesthesia Director, Doctor CC on 4/4/2017 at 9:48 AM. In response to not cleaning medication vials prior to access, Doctor CC stated, "No, that is not our policy and we have gone over and over this."

At 10:00 AM on 4/4/2017 Circulating Nurse DD was observed to have both ears exposed (surgical bouffant tucked behind) while prepping the operating room for Patient #33's shoulder surgery.

The following observations in the Operating Room were made on 4/4/2017 between 10:53 AM and 12:05 PM for Patient #33's left shoulder surgery:
At 10:53 AM Doctor of Anesthesia II was observed to have both ears exposed while giving intravenous sedation medication to Patient #33.
At 11:15 AM Physician Assistant HH left the operating room and entered the sterile corridor with gloves still on. At this time, Doctor EE entered the operating room and did not perform hand hygiene. Surgical Technician FF whispered to Doctor EE who then said, "Oh ya, ya," and performed hand hygiene at that time.
At 11:18 AM Nurse DD performed the betadine scrub/paint to Patient #33's left arm while ears were still exposed. Surgical Technician FF was observed to have FF's back to the sterile instrument table for 1 minute before turning side ways towards the table.
Between 11:21 AM and 11:24 AM, Technician DD, Doctor EE, and Physician Assistant HH all had their backs to the sterile instrument table.
These findings were discussed with, and confirmed per interview with Chief Nursing Officer E on 4/4/217 at 12:10 PM. Nurse E stated, "You are right, your back is not to be to the table."


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Observation of medication pass:

On 4/4/17 at 11:30 AM Staff I was observed administering Toradol (non-sterodial anti inflammatory medication) via intravenous route on Patient #21. Staff I was observed performing hand hygiene upon entering Patient #21's room but did not don gloves and proceeded to access patients intravenous port in left hand, Staff I swabbed port with alcohol wipe and attached syringe via needless connection and administered medication.

The above deficiency was confirmed in interview with RN Manager D on 4/4/17 at 11:45 AM and with Infection Control Officer H on 4/4/17 at 12:04 PM who both stated that gloves should have been donned prior to administration of intra venous medication.

Observation of wound care:

On 4/4/17 at 11:35 AM Staff I was observed performing dressing change on Patient #21. Staff I performed hand hygiene upon entering patient room and donned gloves then removed surgical dressing from lower back, applied a new dressing and proceeded to remove intravenous catheter from left hand without changing gloves or performing hand hygiene between tasks.

The above deficiency was confirmed in interview with RN Manager D on 4/4/17 at 11:45 AM and with Infection Control Officer H on 4/4/17 at 12:04 PM who both stated that the expectation of staff would be to change gloves after removing old dressing, perform hand hygiene and don clean gloves to apply clean dressing and to change gloves and perform hand hygiene again prior to performing intravenous catheter removal from left hand.

Based on observation, record review, and interview, staff at this facility failed to ensure that alcohol based skin preparations are dry/documented as dry, prior to proceeding with procedures in 1 of 2 observations where an alcohol based skin preparation was used (#32) and in 1 of 12 medical records where alcohol based skin preparations were used (#18).

Findings include:

Per interview with Chief Nursing Officer E on 4/4/2017 at 8:28 AM, regarding the standards of practice followed by surgical services, Nurse E stated that the facility follows AORN (Association of periOperative Registered Nurses), AAMI (Association for Advancement of Medical Instrumentation), CDC (Centers for Disease Control), and APIC (Association of Professionals for Infection Control and Epidemiology.

AORN Guidelines 2017 Published online January 2017, "II.d.3. Adequate time should be provided to allow flammable skin antiseptic agents to dry completely and to allow any fumes to dissipate before applying surgical drapes or using a potential ignition source."

On 4/4/2017 between 8:00 AM and 8:22 AM the following observation was made for Patient #32's spinal pain injection:
Surgical Technician GG used ChloroPrep (an alcohol based surgical skin preparation) to cleanse Patient #32's back. While holding up a sterile towel and watching the clock in the room, GG stated, "A minute is a long time when you are waiting," and after one minute GG applied a drape over the lower part of the prepped area.

This observation was discussed with and confirmed per interview with Chief Nursing Officer, Nurse E on 4/4/2017 at 9:50 AM. In regards to standards of practice for the same day stay area versus the operating room/surgical suite, Nurse E stated, "Yes, we follow AORN (Association of peri-Operative Registered Nurses) guidelines in same day too." Nurse E also stated, "That's interesting," regarding waiting one minute for the ChloroPrep to dry and said, "ChloroPrep dry time is 3 minutes."

A medical record review was conducted on Patient #18's closed same day surgery record on 4/5/2017 at 11:10 AM accompanied by Registered Nurse N, Meditech Manager M, Pharmacist J, Social Worker NN, and joined at 11:20 AM by Same Day Surgery Manager O and Chief Nursing Officer E who confirmed the following finding per interview: Patient #18 had a spinal pain injection on 3/30/2017 and ChloroPrep was used to prepare the surgical site. There is no documentation indicating the prep was dry prior to proceeding with the procedure. Per interview with Manager O regarding documenting that the ChloroPrep is dry, Manager O stated that it would not be necessary because no cautery is used during the procedure. Per interview with Chief Nursing Officer E regarding documenting that the ChloroPrep is dry, Nurse E stated, "That is the expectation."

Based on record review and interview the facility failed to ensure there is a History and Physical and/or an updated History and Physical in the medical record prior to a procedure, in 2 of 30 medical records reviewed (4 and 11). This deficiency directly affects Patients 4 and 11, and potentially affects all patients treated at the facility.

Findings include:

Per review of the facility Medical Staff Rules and Regulations, updated 11/10/16, it states under Section II Medical Records, 2. "...The patient's medical record must contain a medical history and physical examination completed and documented for each patient no more than thirty (30) days before or twenty-four (24) after admission or registration, but prior to surgery or a procedure requiring anesthesia services or local anesthetics...#3...an update must be completed by the attending hospital provider or their designee prior to surgery/procedure."

Per Patient #4's, medical record review on 4/4/17 at 10:00 AM, Patient #4 had a hysterectomy on 12/2/16. There is no same day History and Physical nor a History and Physical Update completed prior to the procedure. This is confirmed during record review on 4/4/17 at 10:00 AM with Meditech Systems Manager M and RN N, who agreed there should be either a same day History and Physical or a History and Physical Update on file.


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A medical record review was conducted on 4/4/2017 at 1:11 PM on Patient #11's closed surgical record accompanied by Registered Nurse N and Meditech Nurse X who confirmed per interview the following finding: Patient #11 had abdominal and breast surgery on 3/2/2017. The history and physical is dated 1/11/2017, more than 30 days prior to the date of surgery.

Based on record review and interview the facility failed to ensure the post anesthesia note contains, at minimum, the following information to ensure the patient has recovered from anesthesia: Respiratory function, rate, airway patency, oxygen saturation, cardiovascular function including pulse and blood pressure, mental status, temperature, pain, nausea and vomiting and hydration; in 21 of 28 medical records with local and/or general anesthesia (1, 2, 3, 4, 11, 12, 13, 14, 16, 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30). This deficiency directly affects Patients 1, 2, 3, 4, 11, 12, 13, 14, 16, 17, 20, 21, 22, 23, 24, 26, 27, 28, 29 and 30 and potentially affect all 122 patients treated during survey.

Findings include:

Per review of facility policy titled Operating Room Anesthesia, revised 5/6/16, it states under Postanesthetic Care it states to include the following in the post note: "Patient's physical condition including stability of vital signs, principle ailment of patient, quantity of blood loss status of blood loss, status of fluid replacement an level of consciousness on entering and leaving the PACU (Post Anesthesia Care Unit)...Oxygen therapy for recovering patient as necessary, special positioning of the patient and special monitoring, if required"

Patient #1's medical record review on 4/4/17 at 8:30 AM revealed Patient #1 had a hysterectomy on 10/28/16 under general anesthesia. The Post Anesthesia Note completed on 10/28/16 at 3:09 PM includes the following: Cardiovascular Function including Pulse, BP (Blood Pressure) and Temp (Temperature): Box checked "Stable"; Respiratory Function including resp. (respirations) rate, airway patency, and O2 Sat (Saturation, level of oxygen in the blood): Box checked "Stable"; Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes: Box checked "Stable"; Post Procedure hydration adequate: Box checked "Stable"; Return of neurologic function in pts (patients) receiving regional anesthesia: Box checked "Stable". This does not constitute a complete Post Anesthesia note with listed Pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is or was nausea/vomiting.

Patient #2's medical record review on 4/4/17 at 9:10 AM revealed Patient #2 had a right hip replacement on 10/19/16 with a spinal injection for anesthesia. The Post Anesthesia Note completed on 10/20 (no year) at 12:40 PM includes the following: Cardiovascular Function including Pulse, BP and Temp: Box checked "Stable"; Respiratory Function including resp. rate, airway patency, and O2 Sat: Box checked "Stable"; Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes: Box checked "Stable"; Post Procedure hydration adequate: Box checked "Stable"; Return of neurologic function in pts receiving regional anesthesia: Box checked "Stable". This does not constitute a complete Post Anesthesia note with listed Pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain, if there is or was nausea/vomiting, and level of function/sensation returned from regional anesthesia (spinal).

Patient #3's medical record review on 4/4/17 at 9:40 AM revealed Patient #3 had a left knee arthroscopy on 11/10/16 under general anesthesia. The Post Anesthesia Note completed on 11/10/16 at 14:01 PM includes the following with a line drawn through the boxes in front of the word "Stable": Cardiovascular Function including Pulse, BP and Temp; Respiratory Function including resp. rate, airway patency, and O2 Sat; Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes: Box checked "Stable"; Post Procedure hydration adequate; Return of neurologic function in pts receiving regional anesthesia. This does not constitute a complete Post Anesthesia note with listed Pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is or was nausea/vomiting.

Patient #4's medical record review on 4/4/17 at 10:00 AM revealed Patient #4 had a hysterectomy on 12/2/16 under general anesthesia. The Post Anesthesia Note completed on 12/2/16 at 12:14 PM includes the following: Cardiovascular Function including Pulse, BP and Temp : Box checked "Stable"; Respiratory Function including resp. rate, airway patency, and O2 Sat: Box checked "Stable"; Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes: Box checked "Stable"; Post Procedure hydration adequate: Box checked "Stable"; Return of neurologic function in pts receiving regional anesthesia: Box checked "Stable". This does not constitute a complete Post Anesthesia note with listed Pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is or was nausea/vomiting.

The above deficiencies were confirmed in interview with Meditech Systems Manager M and Registered Nurse N during record reviews on 4/4/17 between 8:30 AM and 11:12 AM, who were unaware the vital signs, and level of sensation should be documented.


26711

Per interview with Director of Anesthesia, Doctor CC, on 4/4/2017 at 9:35 AM, regarding the post-anesthesia evaluation, Doctor CC stated that any case that has anesthesia attend gets a post-anesthesia The physician has to do it unless it's a MAC (monitored anesthesia care), then the certified registered nurse anesthetist can do it.

A medical record review was conducted on Patient #11's closed surgical record on 4/4/2017 at 1:11 PM accompanied by Registered Nurse N and Meditech Nurse X who, per interview, confirmed the following finding: Patient #11 had general anesthesia for surgery on 3/2/2017. The standardized post anesthesia note is pre-printed with check boxes for assessment criteria as follows: Level of Consciousness: Awake or other; Complications/Follow Up Care: None or other; Cardiovascular Function including Pulse, BP [blood pressure] and Temp [temperature]: Stable or other; Respiratory Function including resp. rate [respiratory], airway patency, and O2 Sat [oxygen saturation]: Stable or other; Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes: Stable or other; Post Procedure hydration adequate: Stable or other; Return of neurologic function in pts [patients] receiving regional anesthesia (an anesthetizing block of a particular body part): Stable or other. All of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #11 did not have a block (regional anesthesia). There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review, Nurse N stated that there were issues with the documentation of this note found earlier in the day as well.

A medical record review was conducted on Patient #12's closed surgical record on 4/4/2017 at 3:10 PM accompanied by Registered Nurse N and Meditech Nurse X who, per interview, confirmed the following finding: Patient #12 had general anesthesia for surgery on 3/13/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #12 did not have a block but the box is checked stable. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.

A medical record review was conducted on Patient #13's closed surgical record on 4/5/2017 at 8:25 AM accompanied by Registered Nurse N, Meditech Manager M and Pharmacist J who, per interview, confirmed the following finding: Patient #13 had general anesthesia for surgery on 3/17/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #13 did not have a block but the box is checked stable. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.

A medical record review was conducted on Patient #14's closed surgical record on 4/5/2017 at 9:05 AM accompanied by Registered Nurse N, Meditech Manager M, Interim Nurse Manager D and Pharmacist J who, per interview, confirmed the following finding: Patient #14 had general anesthesia for surgery on 3/29/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #14 did not have a block but the box is checked stable. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.

A medical record review was conducted on Patient #16's closed surgical record on 4/5/2017 at 10:20 AM accompanied by Registered Nurse N, Meditech Manager M and Social Worker NN who, per interview, confirmed the following finding: Patient #16 had general anesthesia for surgery on 3/17/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is other than mention that the block is working well. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.

A medical record review was conducted on Patient #17's closed surgical record on 4/5/2017 at 10:45 AM accompanied by Registered Nurse N, Meditech Manager M, Social Worker NN and Pharmacist J who, per interview, confirmed the following finding: Patient #17 had general anesthesia for surgery on 3/7/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #17 did not have a block but the box is checked stable. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.

A medical record review was conducted on Patient #20's closed surgical record on 4/5/2017 at 11:40 AM accompanied by Meditech Manager M and Pharmacist J who, per interview, confirmed the following finding: Patient #20 had general anesthesia for surgery on 2/23/2017. On the standardized pre-printed post anesthesia note all of the boxes that say "Awake, None, Stable." are checked. There is no documentation of what the vital signs are or any documentation on what any of the medical criteria is. Patient #20 did not have a block but the box is checked stable. There is no documentation regarding principle ailment of patient, quantity of blood loss, or status of blood loss. Per interview with Nurse N during the medical record review.


37420


Patient #21's medical record reviewed on 4/4/17 at 2:30 PM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 4/3/17 states that Patient #21 is having a L5 -S1 microdiscetomy with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes are present under each of the above categories for either Awake/Stable or Other. A single vertical line is drawn through "Awake/Stable" for the entire list of post anesthesia notes and is signed and dated/timed for 4/3/17 at 10:37 am. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #22's medical record reviewed on 4/4/17 at 3:05 PM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 3/31/17 states that Patient #22 is having an extreme lateral interbody fusion with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes are present under each of the above categories for either Awake/Stable or Other. A check mark is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 3/31/17 at 11:56 AM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #23's medical record reviewed on 4/4/17 at 3:40 PM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 4/3/17 states that Patient #23 is having a L total knee replacement with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A circle is placed through "Awake/Stable" for the entire list of post anesthesia notes except the Return of neurologic function in pats receiving regional block and is signed and dated/timed for 4/3/17 at 11:15 am. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #24's medical record reviewed on 4/5/17 at 8:35 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 4/3/17 states that Patient #24 is having a Left total knee replacement with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A single vertical line is drawn through "Awake/Stable" for the entire list of post anesthesia notes and is signed and dated/timed for 4/3/17 at 4:42 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #25's medical record reviewed on 4/5/17 at 9:10 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 10/7/16 states that Patient #25 is having a extreme lateral fusion with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A check mark is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 10/7/16 at 8:3 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #26's medical record reviewed on 4/5/17 at 9:40 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 10/18/16 states that Patient #26 is having a L2/3-L4/5 laminectomy with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A check mark is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 10/18/16 at 11:34 AM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #27's medical record reviewed on 4/5/17 at 10:10 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 10/18/16 states that Patient #27 is having a "R THA, removal of hardware" with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A check mark is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 10/18/16 at 5:43 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #28's medical record reviewed on 4/5/17 at 10:40 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 9/7/16 states that Patient #28 is having a "removal of hardware left knee" with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. An "X" is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 9/7/16 at 6:07 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #29's medical record reviewed on 4/5/17 at 11:10 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 10/21/16 states that Patient #29 is having a Left shoulder arthroscopy with RCR with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. An "X" is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 10/21/16 at 3:15 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

Patient #30's medical record reviewed on 4/5/17 at 11:45 AM revealed that facility form entitled "Oakleaf Surgical Hospital Pre-Anesthetic History and Evaluation" dated 12/14/16 states that Patient #30 is having a right ankle ORIF with general anesthesia planned. On page 2 of this facility form there is a section for "Post Anesthesia Notes:" with lines for Level of Consciousness, Complications/Follow up care, Cardiovascular Function including Pulse, BP and Temp, Respiratory function including resp. rate, airway patency, and O2 sat, Pain control, nausea/vomiting are being assessed and treated with no apparent adverse outcomes, Post Procedure hydration adequate, and Return of neurologic function in pts receiving regional anesthesia. Check off boxes under each of the above categories for either Awake/Stable or Other. A check mark is written in each "Awake/Stable" box for the entire list of post anesthesia notes and is signed and dated/timed for 12/14/16 at 4:28 PM. There are no indications of pulse, blood pressure, temperature, respirations, airway patency, oxygen saturations, level of pain and if there is/was nausea and vomiting. This does not constitute a complete Post Anesthesia note.

The above deficiencies were confirmed in interview on 4/4/17at 2:30 PM-3:40 PM and 4/5/17 at 8:35 AM-11:30 AM at the time of medical record review with Staff Y and Meditech System Manager M who stated this was the way it was always done at the facility and the "PACU Note" in the bottom right hand corner of the facility form "Anesthesia Record" has vitals on it and those are considered the post anesthesia vitals but are vitals taken upon arrival into the PACU.