HospitalInspections.org

Based on medical record review, and staff interview, the facility failed to ensure surgical consents were legible for 5 of 8 patients reviewed (#20, #27, #28, #29, #30) . The findings were:

1. Review of the medical record for patient #20 showed s/he was admitted to the facility on 9/26/22 for ankle reconstruction. Review of the surgical consent showed the medical condition and surgical procedure were hand written and illegible.

2. Review of the medical record for patient #27 showed s/he was admitted to the facility on 9/30/22 for right gluteal muscle repair. Review of the surgical consent showed the medical condition and surgical procedure were handwritten and illegible.

3. Review of the medical record for patient #28 showed s/he was admitted on 8/8/22 for a right knee replacement. Review of the surgical consent showed the medical condition and surgical procedure were handwritten and illegible.

4. Review of the medical record for patient #29 showed s/he was admitted on 8/22/22 for a left knee replacement. Review of the surgical consent showed the medical condition and surgical procedure were handwritten and illegible.

5. Review of the medical record for patient #30 showed s/he was admitted on 8/29/22 for a shoulder surgery. Review of the surgical consent showed the medical condition and surgical procedure were handwritten and illegible.

6. Interview on 11/3/22 at 10:24 AM with the surgical director confirmed the surgical consents were not legible. She further stated the surgeon who obtained the consents was the only one who still hand-wrote the procedure.

Based on medical record review, staff interview, and professional standards review, the facility failed to ensure a post-anesthesia evaluation was completed for 7 of 9 patients (#14, #16, #20, #27, #28, #29, #30 ) reviewed for surgical procedures requiring anesthesia services. The findings were:

1. Medical record review for patient #14 showed s/he was admitted to the facility on 9/1/22 for a cesarean section regarding term pregnancy. Review of the entire medical record, which included all operative information, showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview with the nursing director of the obstetrics department on 11/3/22 at 9:15 AM confirmed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional for patient #14.

2. Medical record review for patient #16 showed s/he was admitted to the facility on 9/7/22 for a cesarean section regarding term pregnancy. Review of the entire medical record, which included all operative information, showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview with the nursing director of the obstetrics department on 11/3/22 at 9:15 AM confirmed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional for patient #16.

3. Medical record review for patient #20 showed s/he was admitted on 9/26/22 for a right ankle reconstruction. Review of the entire medical record, which included all operative information showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview on 11/3/22 at 10:30 AM with the surgical services director confirmed there was no documented post-anesthesia evaluation.

4. Medical record review for patient #27 showed s/he was admitted on 9/30/22 for repair of the right gluteal muscle. Review of the entire medical record, which included all operative information showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview on 11/3/22 at 10:30 AM with the surgical services director confirmed there was no documented post-anesthesia evaluation.

5. Medical record review for patient #28 showed s/he was admitted on 8/8/22 for a right total knee arthroplasty. Review of the entire medical record, which included all operative information showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview on 11/3/22 at 10:30 AM with the surgical services director confirmed there was no documented post-anesthesia evaluation.

6. Medical record review for patient #29 showed s/he was admitted on 8/22/22 for a left total knee arthroplasty. Review of the entire medical record, which included all operative information showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview on 11/3/22 at 10:30 AM with the surgical services director confirmed there was no documented post-anesthesia evaluation.

7. Medical record review for patient #30 showed s/he was admitted on 8/8/22 for a right total knee arthroplasty. Review of the entire medical record, which included all operative information showed the facility failed to ensure a post-anesthesia evaluation was completed by a qualified professional. Interview on 11/3/22 at 10:30 AM with the surgical services director confirmed there was no documented post-anesthesia evaluation.

8. According to the American Association of Nurse Anesthesiology Postanesthesia Care Practice Considerations, ..."Determining Readiness for PACU (Post Anesthesia Care Unit) Dishcharge...Before the patient can be transferred to home or another unit, the patient must be stabilized. The anesthesia professional works with the PACU staff to evaluate the patient and prepare the patient for discharge. In additions to adequate airway, oxygentation and ventilation, PACU patient discharge criteris include, but are not limited to the following, Alert and oriented mental status, body temperature of at 96.8 degress Fahrenheit, acceptable pain relief..." Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/postanesthesia-care-practice-considerations.pdf?sfvrsn=677a6ac5_10, 11/8/22.




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