HospitalInspections.org

Based on review of documentation and staff interview, the hospital failed to submit the hospital's budget plan to the state health planning agency as required by the regulation. Failure to submit the hospital budget plan specific to the individual hospital to the state health planning agency prevented the state health planning agency from reviewing the hospital's capital expenditures specific to that facility. The hospital administrative staff identified 1 of 1 hospital budget plan.


Findings include:

1. Review of documentation revealed the lack of evidence the hospital submitted the hospital's budget to the state health planning agency.

2. During an interview on 8/22/18 at 10:25 AM, the Finance Manager acknowledged the hospital staff failed to send the hospital's budget to the state health planning agency.

Based on document review and staff interviews, the administrative staff failed to ensure the safe transport of pediatric patients throughout the facility for 1 of 1 pediatric surgical patient (Patient #15) when the surgical staff carried a pediatric patient to surgery. Failure to promote care in a safe setting as staff nurses transport pediatric patients throughout the facility by carrying the child. This practice could potentially result in a nurse falling and landing on the child or dropping the child if the child became restless, thus injuring the child. The facility reported performing 99 pediatric surgeries per year.


Findings include:

1. Review of policy "Visitors and Traffic Control in the PACU," reviewed 08/2018, revealed in part, "Purpose: To specify persons allowed in the Post Anesthesia Care Unit and how patients are transported... Patients may be carried upon age and weight appropriate situations by staff with another staff member assisting to transport IV or other medical equipment..."

2. Review of Patient #15's medical revealed Patient #15 was a pediatric patient that underwent a surgical procedure that required general anesthesia. Transfer data on page 7 of surgical record revealed the transfer method was to carry the patient.

3. During an interview on 8/28/2018 at 0827 AM, the Operating Room Manager revealed she remembered this child. She stated staff nurses carried the child from the Post Anesthesia Care Unit I to Post Anesthesia Care Unit II. The Operating Room Manager reported it is common practice for nurses to carry pediatric patients from Post Anesthesia Care Unit I to Post Anesthesia Care Unit II. A nurse will hold the patient as another nurse holds the patient's IV bag as both nurses walk down the hall together, to ensure the IV access does not get pulled out.

Based on review of policies/procedures and staff interviews, the hospital failed to update the patient rights' policy to ensure all patients were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend. Failure to provide patients with current visitation rights could potentially result in the hospital staff inappropriately restricting a patient's visitors.

The hospital staff identified an average number of patients served in the following areas:
- Average daily inpatient (acute and swing bed) census - 9
- Physical Therapy patient visits - 41,889 per year
- Occupational Therapy patient visits - 4,033 per year
- Speech Therapy patient visits - 3.050 per year
- Cardiac Rehabilitation patient visits - 2,958 per year
- Respiratory Therapy treatments - 7,468 per year
- Emergency Room visits - 10,775 per year
- Surgery procedures - 3,125 per year
- Laboratory procedures - 90,272 per year
- Radiology procedures - 21,665 per year
- Diabetic Education patient visits - 747 per year


Findings include:

1. Review of hospital policy "Patient's Rights and Responsibilities Policy," revised 1/2018, revealed the policy lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 8/20/18 at 4:20 PM, the Director of Information Technology (IT)/Quality/Care Coordination acknowledged the Patient Rights policy lacked the current patient visitation rights information as required by the regulations.

Based on document review, observations, and staff interviews, the hospital staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. Failure to provide all patients with current visitation rights could potentially result in the hospital staff limiting/restricting access of visitors to patients that infringed on the patient's right to have a support person present when they are provided any type of care, services, or treatment modalities. The hospital staff identified a current census of 9 patients - 6 acute patients, 2 special care unit patients, and 1 obstetric patient.

The hospital staff identified an average number of patients served in the following areas:
- Average daily inpatient (acute and swing bed) census - 9
- Physical Therapy patient visits - 41,889 per year
- Occupational Therapy patient visits - 4,033 per year
- Speech Therapy patient visits - 3.050 per year
- Cardiac Rehabilitation patient visits - 2,958 per year
- Respiratory Therapy treatments - 7,468 per year
- Emergency Room visits - 10,775 per year
- Surgery procedures - 3,125 per year
- Laboratory procedures - 90,272 per year
- Radiology procedures - 21,665 per year
- Diabetic Education patient visits - 747 per year


Findings include:

1. Review of undated patient handout, "Patient Rights and Responsibilities", revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 8/20/18 at 4:20 PM, the Director of Information Technology (IT)/Quality/Care Coordination acknowledged the Patient Rights patient handout lacked the current patient visitation rights information as required by the regulations.

Based on document review and staff interviews the administrative staff failed to ensure nursing staff fully documented appropriate assessments during blood and blood product transfusions for 4 of 4 reviewed patient medical records where the patient received a blood transfusion (Patient #17, Patient #18, Patient #19, and Patient #22).

Failure to provide appropriate assessments on patients receiving blood and blood products could potentially result in a patient having a lethal reaction to the transfusion and staff not addressing the reaction until it is too late for the patient to escape death. The hospital performed 225 blood transfusions annually.


Findings include:

1. Review of policy "Blood Product Administration," revised 02/2018, revealed in part, "Start the blood transfusion slowly at a rate of 120 ml/hour ... In 5 minutes recheck vitals Blood Pressure and Temperature, Respirations and Pulse (BP and TPR). If stable with no apparent symptoms of reactions. (Stay with the patient for the first 15 minutes of infusion.) 2. Recheck vitals every 15 minutes for 30 minutes, [every] 30 minutes [twice], then hourly during the transfusion ..."

2. Review of Patient #17's medical record revealed Patient #17 received 6 units of blood. Registered Nurse (RN) BB administered 5 units of blood on 2/10/2018 at 1:46 PM and 4:12 PM, and on 2/11/2018 at 11:48 AM, 2:07 PM, and 6:35 PM. RN BB failed to perform vital sign assessments in the timeframe dictated in the facility's Blood Product Administration policy. RN CC administered 1 unit of blood to Patient #17 on 2/11/2018 at 8:23 PM. RN CC failed to perform complete sets of vital signs in the timeframe dictated in the facility's Blood Product Administration policy.

3. Review of Patient #18's medical record revealed Patient #18 received 4 units of blood. RN DD started administering the blood on 4/16/2018 at 12:10 PM, and failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration policy.

Review of Patient #18's medical record revealed Patient #18 received one unit of blood on 4/16/2018 at 1:25 PM. RN EE started administration of the blood and failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration policy.

Review of Patient #18's medical record revealed Patient #18 received one unit of blood on 4/17/2018 at 8:51 AM. RN F started administration of the blood and failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration policy.

Review of Patient #18's medical record revealed Patient #18 received one unit of blood on 4/17/2018 at 11:17 AM. RN GG started administration of the blood and failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration policy. RN HH assumed responsibility for Patient #18's care at 11:53 AM. RN HH failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration Policy for the remainder of the time RN HH administered the blood.

4. Review of Patient #19's medical record revealed Patient #19 received one unit of blood on 6/20/2018 at 1:50 AM. RN II started administration of the blood and failed to perform vital signs in the timeframe dictated in the facility's Blood Product Administration policy.

5. Review of Patient #22's medical record revealed Patient #22 received one unit of blood on 6/20/2018 at 2:50 AM. RN LL started administration of the blood and failed to perform vital signs in the timeframe dictated in the facility's Blood Administration policy.

6. During an interview on 8/27/2018 at 3:01 PM, Inpatient Nurse Coordinator GG reported the hospital's policy required the nursing staff to check a patient's vital signs within 5 minutes of starting the infusion, every 15 minutes for two sets of vital signs, every 30 minutes for two sets of vital signs, and then hourly until the transfusion finished. She expected the nursing staff to follow the hospital's policy and confirmed Patient #17, Patient #18, Patient #19, and Patient #22's medical records lacked documentation the nursing staff performed the vital sign checks in accordance with hospital policy.

Based on document review and staff interviews the facility failed to complete and properly execute informed consent forms for 4 of 4 obstetrical records and procedures reviewed (Patient #4, Patient #5, Patient #6, and Patient #7).

Failure to to perform a complete and properly executed informed consent form placed the patient at risk for not fully understanding the procedure performed, the risks and benefits of the procedure, and the assurance that the staff answered the patient's questions and concerns prior to authorizing the staff to perform the procedure. The CNO/COO identified the hospital staff performed approximately 170 births per year.


Findings include:

1. Review of the policy "Informed Consent," revised 08/2018, revealed in part, "...all inpatient and outpatient medical records must contain a properly executed informed consent form prior to conducting any procedure or other type of treatment that requires informed consent." "A properly executed informed consent form contains the following minimum elements:... Date and time the informed consent form is signed by the patient or patient's representative." "Anesthesia Department Staff... shall review the anesthesia indicated for the procedure/treatment including risks and benefits."

2. Review of Patient #4's medical record revealed the Consent for The Administration of Anesthesia and the Consent for Operation or Other Procedure lacked documentation of the time when Patient #4 signed the consents.

3. Review of Patient #5's medical record revealed the Consent for Blood Transfusion and the Consent for the Administration of Anesthesia lacked documentation of the time when Patient #5 signed the consents.

4. Review of Patient # 6's medical record revealed the Consent for Operation or Other Procedure lacked documentation of the date and time Patient #6 signed the consent.

5. Review of Patient # 7's medical record revealed the Consent for the Administration of Anesthesia and the Consent for Operation or Other Procedure lacked documentation of the date and time Patient #7 signed the consents. The Consent for Administration of Anesthesia lacked documentation of the type of anesthesia Patient #7 would receive and if the staff member reviewed the information with Patient #7.

6. During an interview on 8/27/2018 at 1:00 PM with RN F, OB Staff Nurse and House Supervisor, revealed OB nursing staff routinely completed the consents for Blood Transfusion, Consent for the Administration of Anesthesia, and Consent for Operation or Other Procedure on all patients admitted in labor "just in case" the patient would need a blood transfusion, administration of anesthesia, or a Caesarian Section (C-Section). RN F verified each consent lacked the required documentation on the consent forms.

7. During an interview on 8/28/18 at 10:00 AM, RN H, Manager of Care Coordination, Quality and Risk Management, verified the hospital staff failed to complete the required elements of a consent form which the hospital required for a properly executed informed consent form.

Based on observation, document review, and staff interviews, the hospital failed to maintain x-ray emitting equipment in 1 of 2 x-ray rooms to ensure the safety of personnel operating the equipment (Radiology - Digital Diagnostic/General X-Ray/Trauma Room). The length of the x-ray emitting control cord could allow the personnel operating the x-ray equipment to enter into the field of exposure.

Failure to ensure the length of the x-ray exposure cord could not allow personnel operating the x-ray equipment from the entering the field of exposure while taking an x-ray could potentially result in unnecessary radiation exposure to staff which could cause cancer or death. The radiology staff reported an average of 540 x-rays completed every month with the equipment in this room.


Findings include:

1. Observation during tour of the Radiology Department on 8/21/18 at 9:20 AM, revealed a 6 foot long x-ray emitting equipment control cord in the Digital Diagnostic/General X-Ray/Trauma Room that could extend outside the safety barrier for the personnel operating the equipment.

2. Review of policy/procedure "Shielding in Radiology," dated 2/2017, revealed, in part, "All radiology personnel will wear a protective lead apron when anywhere within 6 feet of the x-ray beam or anywhere in the room during fluoroscopy..."

The policy/procedure failed to address the length of the exposure control cord that could allow the personnel operating the x-ray equipment to enter into the field of exposure.

3. During an interview on 8/21/18 at 9:20 PM, the Manager of Radiology confirmed the x-ray emitting equipment cord in the Digital Diagnostic/General X-Ray/Trauma Room could extend outside the safety barrier for the personnel operating the equipment. The Manager of Radiology stated they knew the x-ray emitting eqipment control cord could not extend outside the safety barrior when the radiology technician completed an x-ray procedure. The Manager of Radiology stated they use the x-ray room to perform general x-rays, chest x-rays, and trauma x-rays.

I. Based on observation, document review, and staff interviews, the hospital staff failed to ensure the emergency department staff removed expired emergency supplies from 1 of 1 supply cupboard in the Emergency Department's Trauma Bay 1.

Failure to ensure the Trauma Bay 1 supply cabinet contained unexpired supplies resulted in the emergency department staff not having readily available access to supplies which are sterile and of guaranteed quality by the manufacturer, potentially resulting in a life-threatening delay in treatment for a patient. Review of the Skiff Medical Center Statistical Comparative Report identified an average of 925 emergency patients per month.


Findings include:

1. Observation on 8/23/2018 at 8:55 AM staff revealed the following:

a. 1 of 1 PleuraGuide Disposable Chest Tube Kit (a flexible plastic tube inserted through the chest wall into the lung to remove air, fluid, or pus), expired 5/31/2018

b. 1 of 1 Two-Lumen Central Venous Catheter Kit (a small flexible tube placed into a large vein in the neck, chest, groin or arm to give fluids and medications), expired 1/31/2018

c. 1 of 1 Sure Step Foley Catheter Tray System (a flexible tube passed through the urethra into the bladder to drain urine), expired 2/2018

d. 1 of 1 Nellcor Pediatric Colormetric CO2 Detector (used to confirm the hospital staff appropriately placed a tube in the patient's airway to allow them to breathe for a patient who can't breathe on their own), expired 6/2018

2. During an interview at the time of the observations, RN C, Trauma Coordinator and Clinical Resource Nurse and RN D, Safety and Security, verified the supplies had expired and the staff should not use the supplies.

3. Review of the "Trauma Bay Checklist," labeled August 2018, located on a clipboard within the Trauma Bay 1 supply cupboard, revealed the staff checked the cupboard daily for the presence of supplies and the staff initialed that they had checked the cupboard. The Trauma Bay Checklist failed to direct the hospital staff to check for outdated supplies.

4. During an interview on 8/23/2018 at 8:58 AM, RN C, Trauma Coordinator and Clinical Resource Nurse, indicated the Emergency Department night shift nursing staff was responsible for checking supplies every night and checking to see if the supplies had expired.

4. During an interview on 8/23/2018 at 9:56 AM, the CNO revealed the hospital lacked a policy that required the staff to check for expired supplies and remove them from the patient care areas.







38211


II. Based on document review, staff interviews, and observations, the administrative staff failed to ensure the Director of Support Services maintained a current and complete list of all patient care equipment to include Physical Therapy equipment in 1 of 1 off-site Physical Therapy Clinic located in Colfax, Iowa. Failure to ensure the facility keeps a detailed list of all medical equipment resulted in the staff failing to test a treadmill and an ultrasound machine for patient safety for a 2 year and 8 month span, instead of annually. Lack of Preventative Maintenance(PM) checks on a treadmill and an ultrasound machine could potentially result in patient injury or death if the staff failed to detect an electrical short. The facility staff identified serving approximately 25 patients per month at the off-site Physical Therapy Clinic.


Findings include:

1. Review of the Medical Equipment Management Plan, effective 05/2018, revealed in part, "The Medical Equipment Management Plan ... serves to provide a framework to promote the safe and effective use of equipment for diagnosis, monitoring, treatment and direct patient care ... The objectives of the Medical Equipment Management Plan are to ... Maintain a medical equipment inventory."

2. Review of the document "Active Equipment with [Preventative Maintenance Information] By Department," report created 8/21/2018 at 7:14 AM, revealed the staff did not include the equipment at the off-site physical therapy clinic in Colfax, Iowa in the equipment list.

3. Review of the document "Active Equipment [Preventative Maintenance] Information," created on 8/26/2018 at 11:09 AM, revealed the hospital staff failed to include 11 pieces of patient equipment on the inventory on the list of equipment which staff needed to check for safety.


4. Observation on 8/22/2018 at 3:00 PM at the off site physical therapy clinic in Colfax, Iowa revealed:

a. 1 of 1 RICH-MAR CORP ULTRASOUND UNIT, last preventative maintenance date 12/2016. Review of the sticker revealed the maintenance staff should check the device every 12 months for safety.

b. 1 of 1 QUINTON INSTRUMENT CO. TREADMILL, last preventative maintenance date 12/2016. Review of the sticker revealed the maintenance staff should check the device every 12 months for safety.

5. During an interview on 8/22/2018 at 4:00 PM, the Director of Physical Therapy Services confirmed the maintenance staff last checked the equipment on 12/2016.

6. Review of an email provided by the Director of Support Services, dated 8/24/2018, confirmed the main inventory list "Active Equipment With [Preventative Maintenance Information] By Department" was not up to date.

I. Based on document review, observation, and staff interviews, the acute care hospital's administrative staff failed to ensure the operating room staff followed the manufacturer's recommendations for cleaning endoscopes (long, flexible devices used by physicians to look inside a patient's body). Please refer to A-0749.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to provide a sanitary environment to avoid sources of transmission of infections and communicable diseases. The hospital's surgical staff identified approximately 360 surgical procedures that used endoscopes from March 2018 (implementation of the new policy) to August 2018.


II. During the recertification survey that ended on 8/28/18, the on-site survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Infection Control (42 CFR 482.42). The hospital staff failed to ensure the operating room staff followed the manufacturer's recommendations for cleaning endoscopes.

While on-site, the survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 8/22/18. The administrative staff promptly took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the survey when the administrative staff took the following actions:

a. contacted the endoscope manufacturer to obtain any remedial actions necessary to remediate the prior deficient endoscope cleaning practices.

b. arranged for the hospital staff to weekly check a commercial service to determine if the endoscope manufacturer released new instructions for cleaning the endoscopes, and created a process for formally communicating the changes to the operating rooms nursing leadership.

c. created a process to address any changes in practice suggested by the endoscope manufacturer's representative, and compare the suggested changes to the existing formal cleaning instructions supplied by the endoscope manufacturer.

d. updated the policy on endoscope cleaning to reflect the manufacturer's recommendations.

e. created a skill competency using the manufacturer's recommendations for cleaning the endoscopes.

f. re-trained all staff who clean endoscopes using the new competencies and validated the staff member's ability to cleanse the endoscope according to the manufacturer's recommendations.

Based on document review, observation, and staff interview, the hospital staff failed to ensure 2 of 2 observed Operating Room (OR) staff members (Surgical Technician A and Registered Nurse B) followed the manufacturer's instructions for use when cleaning endoscopes.

Failure to follow the manufacturer's instructions for use while cleaning the endoscopes could potentially result in the cleaning process failing to remove all of the bacteria and debris in the endoscope, which could then potentially infect a different patient since the staff members believed the scope was safe to use on another patient. The hospital's surgical staff identified approximately 360 surgical procedures that used endoscopes from March 2018 (implementation of the new policy) to August 2018.

Findings include:

1. Review of the FujiFilm EC-600 WL endoscope (a long, flexible device used by physicians to look inside a patient's body) Operation Manual, not dated, revealed the manufacturer required surgical staff to perform the following steps while cleaning the endoscope following use on a patient:

a. check the endoscope for any leaks prior to cleaning (on the counter and in water);
b. wipe off the outside of the endoscope with a soft cloth or sponge in a detergent solution;
c. brush the end of the endoscope inserted into the patient with a soft brush;
d. clean the holes housing the buttons with a soft brush. The staff MUST cleanse the holes at least three times with a brush;
e. clean the long, flexible tubes in the endoscope with a soft brush. The staff MUST cleanse the tubes at least three times with a brush;
f. flush the long, flexible tubes in the endoscope with detergent solution;
g. rinse the endoscope with clean water and then flush the long, flexible tubes in the endoscope with clean water;
h. remove the endoscope from water, dry off any remaining water, and proceed to use a high level disinfectant (a chemical solution designed to kill all bacteria, viruses, and fungi, but not necessarily bacterial spores).

2. Review of the policy "endoscope cleaning," revised 3/2018, revealed the policy failed to follow the manufacturer's requirements for cleaning the endoscope. The hospital's policy failed to require the staff to perform the following actions while cleaning the endoscopes:

a. perform the leak test under the water;
b. wipe off the outside of the endoscope with a soft cloth or sponge in the detergent solution;
c. brush the end of the endoscope inserted into the patient with a soft brush;
d. cleanse the holes housing the buttons with a soft brush at least three times;
e. cleanse the long, flexible tubes in the endoscope with a soft brush at least three times.

3. Observations on 8/21/18 at 12:01 PM revealed Surgical Technician (ST) A cleaning a FujiFilm EC-600 WL endoscope. ST A followed the hospital's policy on cleaning the endoscope. Since ST A followed the hospital's policy on cleaning the endoscope, ST A failed to perform the following manufacturer recommended steps in cleaning the endoscope:

a. perform the leak test under the water;
b. wipe off the outside of the endoscope with a soft cloth or sponge in the detergent solution;
c. brush the end of the endoscope inserted into the patient with a soft brush;
d. cleanse the holes housing the buttons with a soft brush at least three times;
e. cleanse the long, flexible tubes in the endoscope with a soft brush at least three times.

4. Observations on 8/22/18 at 9:00 AM revealed Registered Nurse (RN) B cleaning a FujiFilm EC-600 WL endoscope. RN B followed the hospital's policy on cleaning the endoscope, referring to the hospital's policy multiple times during the process. Since RN B followed the hospital's policy on cleaning the endoscope, RN B failed to perform the following manufacturer recommended steps in cleaning the endoscope:

a. perform the leak test under the water;
b. wipe off the outside of the endoscope with a soft cloth or sponge in the detergent solution;
c. brush the end of the endoscope inserted into the patient with a soft brush;
d. cleanse the holes housing the buttons with a soft brush at least three times;
e. cleanse the long, flexible tubes in the endoscope with a soft brush at least three times.

5. During an interview on 8/22/18 at 12:15 PM, the Operating Rooms (OR) Nurse Manager revealed she revised the policy for endoscope cleaning in March 2018. She relied on the manufacturer's instructions for use, guidance from organizations that created recommendations for cleaning endoscopes, and the manufacturer's representative's recommendations when she revised the endoscope cleaning policy.. The OR Nurse Manager stated the manufacturer released the most current version of the manufacturer's instructions for use in January 2018, and she included the January 2018 revised version of the manufacturer's instructions for use with the documents she reviewed to revise the policy.

6. During an interview on 8/22/18 at 3:15 PM, the OR Nurse Manager acknowledged the hospital's policy on cleaning endoscopes failed to require the staff to follow all of the manufacturer's recommended steps in cleaning endoscopes.

Based on document review and staff interviews, the administrative staff failed to ensure the anesthesia providers documented performing appropriate and adequate post-operative assessments for 2 of 5 surgical patient records reviewed (Patient #15 and Patient #16).

Failure to perform and document an adequate post-operative assessment could potentially result in the anesthesia staff failing to detect a patient developing a complication from the anesthesia, and failing to treat a life-threatening complication. The hospital staff performed approximately 1,4000 surgical procedures per year.


Findings include:

1. Review of the document "Anesthesia Rules and Regulations," approved 02/2017, revealed in part, "The post-anesthesia evaluation should not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation. If the patient is unable to participate in the post-anesthesia assessment, the evaluation should still be completed and documented within 48 hours with a notation that the patient was unable to participate and why..."

2. Review of Patient #15's medical record revealed Patient #15 underwent a surgical procedure with general anesthesia (administration of medications to render a patient unconscious and unable to feel pain during a surgical procedure). The Chief CRNA (Certified Registered Nurse Anesthetist, a nurse with specialized training to administer anesthesia medications) documented her post-anesthesia assessment (to determine if the patient recovered from the anesthesia) at 9:15 AM. The nursing documentation showed Patient #15 regained consciousness at 9:15 AM. The Chief CRNA failed to document a post-anesthesia assessment after Patient #15 regained consciousness and document Patient #15's vital signs, level of consciousness, or the patient's pain level at the time of the post-anesthesia assessment.

3. During an interview on 8/28/2018 at 9:02 AM, the Chief CRNA confirmed she administered general anesthesia to Patient #15 and she failed to document a post-anesthesia assessment performed on Patient #15 after Patient #15 was awake and responsive.

4. Review of Patient #16's medical record revealed Patient #16 underwent a surgical procedure that required anesthesia. CRNA AA finished administering the anesthesia at 10:28 AM. CRNA AA documented she performed the post-anesthesia assessment on Patient #16 at 9:45 AM (43 minutes before CRNA AA documented she finished administering anesthesia to Patient #16). CRNA AA failed to document Patient #16's vital signs, level of consciousness, or address Patient #16's pain level in the post-anesthesia assessment.

5. During an interview on 8/28/2018 at 9:02 AM, the Chief CRNA confirmed CRNA AA did not document she performed an adequate post-anesthesia assessment on Patient #16, including the patient's vital signs, level of consciousness, or pain level. The Chief CRNA reported she expected the CRNAs to perform the post-anesthesia assessment after completion of the surgical procedure and once the patient can fully participate in the post-anesthesia assessment to determine if the patient had any complications from the anesthesia.