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Based on interview and record review the hospital failed to ensure that the policy and procedure to complete the "Passport to Surgery/ Procedure Pre-Operative Checklist" was done for 8 Patients (18, 14, 15, 32, 33, 34, and 38) of 29 patients reviewed, resulting in the potential of incomplete assessments for Patients 18,14, 32, 33, 34, and 38 by not having a History and Physical in the record prior to going to the operating room and a potential for violation of patients' rights for Patients 14,15, 33 and 34 by not having a consent for surgery/procedure in the record prior to going to the operating room.
Findings:
Review on 1/10/14 of the "Preoperative Assessment and Reassessment" policy dated and revised 11/11 showed that the policy instructed staff that the collected data is used to make judgment and predictions about a patient's response to illness or changes in life process and to identify nursing diagnoses and predict outcomes and that the registered nurse is responsible for ensuring that the preoperative assessment is complete. The policy instructed that the pre-op checklist is utilized to ensure all relevant documentation such as history and physical, consent, labs and all necessary data is in the passport to surgery before a patient is transported to the operating room. The policy further instructed that patients who are deemed ready for surgery must have all required elements on the surgery check-off list or an explanation of why the list is not complete, before transport to the operating room.
1. Review of the medical record on 1/10/14, showed that the hospital admitted Patient 18 for care on 1/10/14. Patient 18 was a 5 year old boy who came to the hospital for surgery on his left eye for cataract removal and intraocular lens implant (a patient's cloudy natural lens is removed and replaced with a synthetic lens to restore the lens's transparency).
The Preoperative checklist dated 1/10/14 at 6:46 a.m., showed that the Pre-op RN-1 (Registered Nurse) documented that the history and physical was "not on chart" and "OR RN notified" (OR RN is the operating room registered nurse.)
1/10/14 at 9:15 a.m., review of the record with the (electronic record specialist for the recovery room) EPIC PACU RN showed no History and physical by the surgeon in the record and that Patient 18 had been taken to the Operating room at 8:49 a.m. The EPIC PACU RN stated that there were two places that the OR RN could have charted that the history and physical was in the record, by updating the Pre-op checklist and by filling out the "Sign In Time Out" but neither had been done.
Further review of the record on 1/10/14 at 12 p.m. showed that the History and physical had been scanned into the EPIC system at 11:01 a.m., after the surgery.
On 1/10/14 at 2 p.m., during an interview, OR RN 2 stated that he had been notified by the pro-op nurse that there was no history and physical in the record, but that this surgeon never entered the history and physical into EPIC (the electronic record) that this surgeon always brought the history and physical with him to the operating room and placed the hand written form into the record and that it was later scanned into the electronic record. OR RN 2 stated he did not document anywhere in the record that the History and physical was not in the record prior to the patient being taken to the operating room.
On 1/10/14 at 2:20 p.m., during an interview, the ADPS (Assistant Director of Perioperative Services) stated that the expectation is that if there is no History and physical in the record there should be a "Hard Stop" and the patient would not go the operating room until it was completed and on the record. The ADPS explained that there were three "Time Outs" that the OR RN is supposed to fill out in the electronic record. The first is a "Sign In time out that address the pre op check list consent, history and physical and labs etc.; the second is the "Pre-incision Time Out" that is done right before incision checking with all staff in the operating room that they are doing the correct procedure to the correct patient on the correct site with the correct equipment; and the third is the "Sign-Out Time Out" that addresses the post op assessment, sponge and sharp counts etc. The ADPS stated that these time outs were presented in educational inservices to all perioperative staff and that the expectation is that all three will be filled out for each patient.
2. Clinical record review of the form called "Passport to Surgery/ Procedure Pre-Procedural Checklist" for Patients 14 and 15 did not show completion prior to surgery.
The consent, history and physical and laboratory results were not checked off as completed for Patients 14, and there was no documentation that a follow up was done for surgical checklist completion prior to the surgical procedure.
Furthermore, the surgical checklist indicated that the consent was not signed for Patient 15, and there was no documentation that a follow up was done for surgical checklist completion prior to the surgical procedure.



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3. On 1/9/14 and 1/10/14, review of the electronic medical record, EPIC (Electronic Privacy Information Center) showed a form titled, "Passport to Surgery/ Procedure Pre-Procedural Checklist." For Patients 32, 33 and 38 there was no documentation on the pre-surgical checklists to reflect the date and time that the histories and physicals were completed by a nurse on the surgical ward, in the pre-operative area or in the operating room prior to the surgical procedures.

4. For Patients 33 and 34 there was no documentation on the pre-surgical checklists to reflect the date and time that any nurse confirmed that the consents for surgery were present in the charts.

In separate interviews with Nurse Manager 1, on 1/9/14 at 1:30 p.m., and Director 1, on 1/10/14 at 10:45 a.m.; both stated that the patients' pre-surgical checklists should be completed prior to the surgical procedures. If the checklist wasn't completed prior to the patients going to surgery then the operating room RN had the responsibility for reviewing and documenting in the checklist that the history and physical and consent were in each medical record.

5. In addition there were items left blank on the checklists for Patients 32, 33, 34, and 38. For instance, Patient 33 had a blank space next to the checklist item: "Time of last breastmilk." Patient 33 was 9 years old and not breastfeeding. At 10:45 a.m., Nurse Manager 1 further stated that if the items in the pre-operative checklist were not applicable then the nurse should document "N/A" on the form and not leave it blank.