HospitalInspections.org

Based on clinical record review and staff interview it was determined the governing body failed to ensure the quality of care provided by the patient's surgeon included the physician informing the patient of the necessity of placing a stent during surgery for one of 14 (Patient # 27) patients reviewed for surgical consents. The total sample size was 42 and the current census at the time of the survey was 268.

Findings include:

Review of the clinical record for Patient # 27 was completed on 09/16/10. The patient was scheduled for outpatient surgery on 04/13/10 for treatment of bladder cancer. The scheduled procedure was a cystoscopy (viewing the bladder) and transurethral resection of bladder tumors (removal of bladder tumors by way of the urethra). The patient signed a consent for surgery with the knowledge of these two procedures. The operative note signed by the surgeon revealed a stent was placed in the right ureter during the procedure. The clinical record lacked evidence the patient was informed of this stent insertion after recovery from anesthesia.
Interview with the surgeon (Staff C) on 09/15/10 at 2:30 PM., confirmed the medical necessity of placing the stent after discovering a tumor at the ureter opening. During this interview Staff C confirmed the clinical record lacked evidence the patient had been informed of the placement of the stent.

This deficiency substantiates Complaint Number OH00056393