HospitalInspections.org

Based on record review, interview, and observations, the hospital failed to ensure three (Staff B, J, and K) of four surgical staff were competent to supervise and /or perform disinfection / sterilization practices in accordance to manufacturer's guidelines and national standards of practices for endoscopes, endoscope accessories, and liquid chemical sterilant processing systems (Steris System 1E).

These failed practices had the potential to result in inadequate pre-cleaning and disinfection / sterilization of instruments and equipment and to increase the risk of cross contamination to the patients receiving endoscopic procedures.

Findings:

A review of the personnel files for Staff B, J, and K showed no evidence of competency regarding: pre-cleaning endoscope using proper enzyme dilution, endoscope auxillary water tubes, adenosine triphosphate testing, immediate use of requirement for Steris System 1E, Steris System 1E filter change and chemical testing strip documentation.

On 04/12/18 at 8:39 am, Staff B stated the operating room had been under the directorship of three or four different staff prior to her becoming the OR Manager. Staff B stated staff competencies were an area that needed improvement. Staff B stated in the past, competencies were scanned, but none of the documents could be found. Staff B stated all evidence of staff competency would be in the employee's personnel file.

On 04/09/18 at 12:22 pm, the surveyor observed Staff K reprocess an endoscope in simulation. (Refer to A-0749)

Based on record review and interview the hospital failed to ensure the EMR (electronic medical record) reflected sufficient documentation of assessment, interventions, treatments and patients' responses to demonstrate the patients' progress and any changes in condition as evidenced by:

I. Pre-operative assessments for a sample of four (Patient #1, 5, 11 and 12) of 20 patient medical records reviewed, post-anesthesia nursing assessments for a sample of nine (Patient #1, 4, 5, 6, 7, 8, 9, 10, and 30) of 20 patient medical records reviewed, and completion of pre-operative checklists for a sample of four (Patient #1, 11, 17, and 18) of 20 patient medical records reviewed to ensure the patient was ready for surgery per hospital policy,
II. Assessment of surgical incision sites, dressings, notification of physician and decision to discharge for one (Patient #2) of a total sample of 20 patient medical records reviewed
III. Vital signs including oxygen saturation pre/post-operatively for one (Patient #1) of a total sample of 20 patient medical records reviewed,

This failed practice resulted in the delay in patient care decisions for one patient (Patient #1) of a total sample of 20 patients medical records reviewed who had a significantly elevated blood pressure prior to surgery and required medication to lower blood pressure in the operating room (OR), one (Patient #2) of a total sample of 20 patient medical records reviewed who had significant bleeding from a surgical incision site, and the potential risk to all patients due to the unavailability of pertinent information to make timely medical and nursing decisions.

Findings:

Review of hospital policy titled "Assessment/Reassessment Guidelines - Interdisciplinary" showed decisions regarding care were made based on analysis of assessment data ...reassessment were performed to determine a patient's response to care and significant changes in clinical condition. Documentation of the assessment and/or reassessment should be reflected in the patient's EMR.

A review of the ANA (American Nurses Association) Principles of Nursing Documentation dated 2010 showed the implementation of the electronic medical record had provided "an integrated, real-time method" of providing information to the health care providers of a patient's clinical status. To ensure informed decisions and continuity of patient care, timely documentation should be made and maintained by nursing staff.

I. Nursing Assessments and Checklists

Review of hospital policy titled "Pre-operative Checklist" showed a pre-operative nursing assessment and vital signs should be performed prior to surgery. A pre-operative checklist was required for all patients scheduled for surgery and "placed in the patient's chart". Pre-operative checklist is a part of the patient's permanent medical record.

Review of hospital policy titled "PACU (post-anesthesia care unit) Admission Protocol" showed assessment of a patient in the PACU included airway, breathing, cardiac, and consciousness.

Review of hospital policy titled "Post Anesthesia Care Unit" showed at minimum patient's airway (listening and suction if necessary), breathing (check rate, rhythm and depth), and circulation (check pulse, color of nailbeds, and blood pressure) should be assessed when there are no specific orders.

Patient #1 was a 56 year old who presented to the hospital for a laparoscopic cholecystectomy (minimally invasive surgery to remove the gallbladder) secondary to acute on chronic cholecystitis (inflammation of the gallbladder). Patient arrived at the hospital on 04/09/18 at 9:52 am, and was taken to surgery at 10:21 am. Review of the patient's EMR (electronic medical record) showed no evidence of the pre-operative checklist completed and documented in the EMR prior to surgery. At approximately 11:25 am, the patient was transferred from the OR to the PACU for recovery. At the time of discharge at 12:55 pm, a PACU nursing assessment had not been documented in the EMR.

Patient #4 was a 37 year old patient admitted for an EGD (esophagogastroduodenoscopy - a minimally invasive procedure using a flexible scope to diagnose and treat problems of the upper gastrointestinal tract) and laparoscopic cholecystectomy secondary to calculus of the gallbladder without cholecystitis and obstruction. Patient arrived at the hospital on 03/18/18 at 6:33 am, was transported to surgery at 7:12 am, and transferred to the PACU at approximately 8:32 am. Patient was admitted and transferred to the medical-surgical unit at 9:12 am. At 8:32 am, the patient's respiratory status was assessed, no further assessment was documented to include consciousness, cardiovascular and gastrointestinal status following surgery.

Patient #7 was a 49 year old patient admitted for a laparoscopic cholecystectomy secondary to acute cholecystitis. Patient arrived at the hospital on 02/16/18 and admitted to the medical-surgical unit. At 2:07 pm, the patient was transferred to the pre-operative area and taken to surgery at 3:07 pm. At approximately 4:16 pm, the patient was transferred to PACU for recovery and at 4:55 pm, was transported back to the medical-surgical unit. There was no evidence a PACU nursing assessment was documented prior to the patient being transported back to the medical-surgical unit.

Patient #8 was a 72 year old patient admitted for a laparoscopic cholecystectomy secondary to acute cholecystitis. Patient arrived at the hospital on 03/18/18 at 10:08 pm and was admitted to the medical-surgical unit. Patient was transferred to the pre-operative area on 03/20/18 at 9:29 am, and taken to surgery at 9:58 am. Prior to surgery there was no documentation of a nursing assessment in the EMR. At approximately 11:55 am, the patient was transferred to PACU for recovery and at 12:38 pm, was transported back to the medical-surgical unit. At 11:45 am, the patient's respiratory status was assessed, no further assessment was documented to include consciousness, cardiovascular and gastrointestinal status following surgery.

Patient #9 was a 77 year old patient admitted for cystoscopy (procedure to examine the inside lining of the bladder) with bilateral retrograde pyelograms (x-ray imaging of the bladder, ureters [long tubes connecting kidneys to the bladder] and kidneys) and attempted ureteral stent placement on 02/03/18. Patient arrived at the hospital on 01/31/18 at 12:07 pm, and was admitted to the ICU. On 02/03/18 at 8:10 am, patient was taken directly to surgery. At approximately 9:11 am, patient was transferred to PACU for recovery and at 9:57 am, was transported back to the ICU. There was no evidence a PACU nursing assessment was documented prior to the patient being transported back to the medical-surgical unit.

Patient #10 was a 30 year old patient admitted for laparoscopic cystectomy (minimally invasive surgical procedure using a scope for removal of the ovary) and oophorectomy (removal of one or both ovaries) secondary to left ovarian cyst and abdominal pain. Patient arrived at the hospital on 03/18/18 at 11:02 am. Patient was transported to surgery at 11:40 am, and at approximately 1:30 pm, patient was transferred to PACU for recovery. There was no evidence a PACU nursing assessment was documented prior to the patient being discharged at 3:30 pm.

Patient #11 was a 21 year old who presented to the hospital for a laparoscopic cholecystectomy secondary to calculus of the gallbladder with biliary obstruction (blockage of the bile ducts [responsible for carrying bile from the liver and gallbladder through the pancreas to the small intestine]) without cholecystitis and acute gallstone pancreatitis (inflammation of the pancreas [pancreas aids the body in digestion and produces hormones that help regulate how the body processes glucose]). Patient arrived at the hospital on 01/29/18 at 6:19 am, and was taken to surgery at 7:10 am. Review of the patient's EMR showed no evidence of the pre-operative checklist completed and documented in the EMR prior to surgery.

Patient #12 was a 32 year old who presented to the hospital for a laparoscopic appendectomy (surgical removal of the appendix) for acute appendicitis (inflammation of the appendix) with localized peritonitis (inflammation of the inner wall of the abdomen). Patient arrived at the hospital on 01/30/18 at 12:32 pm. Patient was transferred to the pre-operative area at 5:55 pm, and taken to surgery at 6:10 pm. Review of the patient's EMR showed no evidence of a pre-operative assessment performed and documented in the EMR prior to surgery.

Patient #17 was a 27 year old who presented to the hospital for a laparoscopic cholecystectomy secondary to calculus of the gallbladder without cholecystitis and obstruction. Patient arrived at the hospital on 02/12/18 at 5:56 am, and taken to surgery at 7:04 am. At approximately 7:50 am, the patient was transferred to PACU for recovery. There was no evidence a PACU nursing assessment was documented prior to the patient being discharged at 9:38 am.

Patient #18 was a 19 year old who presented to the hospital for a laparoscopic cholecystectomy and secondary to biliary dyskinesia (a motility disorder of that affects the gallbladder where bile cannot move normally in proper direction). Patient arrived at the hospital on 03/26/18 at 6:15 am, and taken to surgery at 7:04 am. At approximately 7:45 am, the patient was transferred to PACU for recovery. There was no evidence a PACU nursing assessment was documented prior to the patient being discharged at 9:38 am.

Patient #30 was a 24 year old who presented to the hospital for a laparoscopic appendectomy for secondary to right upper quadrant pain, calculus of the gallbladder without cholecystitis and without obstruction. Patient arrived at the hospital on 04/10/18 at 6:13 am, and was taken to surgery at 7:07 am. At approximately 8:02 am, the patient was transferred to the PACU for recovery. There was no evidence a PACU nursing assessment was documented prior to the patient being discharged at 9:08 am.

On 04/10/18 at 2:43 pm, Staff I stated a pre-operative checklist was completed and documented in the patient's EMR for each patient having surgery. Staff I stated prior to surgery a focused nursing assessment was performed including neurological status, respiratory, and cardiac and documented in the patient's EMR. Staff I stated additional assessments such as bowel sounds and skin assessment may be performed and documented depending on patient history and presentation. Staff I stated post-operative documentation would include assessment of the patient's respiratory status, cardiac, surgical dressing and vital signs.

II. Assessment of Surgical Incision Sites and Physician Notification

Review of hospital policy titled "Documentation" showed events should be documented including interventions and patient's response when they occur.

Review of hospital policy titled "PACU Admission Protocol" showed dressings were to be checked. The policy failed to provide guidance on how often surgical incisions and dressings were be assessed and documented.

Review of hospital policy titled "Assessment/Reassessment Guidelines - Interdisciplinary" showed when a patient had a "significant change in condition" an assessment/reassessment were to be performed.

Review of hospital policy titled "Discharge Criteria - Out-Patient Surgery" showed patients were to be discharged from Out-Patient Surgery when the following criteria, including but not limited to, had been met ...absence of significant bleeding or drainage from the surgical site. The physician were to be notified and decision regarding discharge were to be made for patients who did not meet criteria.

Patient #2 was a 68 year old patient who presented to the hospital for a laparoscopic cholecystectomy secondary to biliary dyskinesia, non-intractable cyclical vomiting and nausea on 03/23/13. Patient arrived at the hospital at 10:29 am, in the pre-operative area for check in. Patient had a history of cardiac stent placement within the last three months and was on Clopidogrel (Plavix - a blood thinner) 75mg and Aspirin 81mg daily. On 03/21/18 patient received cardiac clearance for surgery with recommendation to continue Clopidogrel and Aspirin secondary to stents placed less than one year. History and Physical dated 03/23/18 by Staff A (surgeon) showed patient was at an increased risk of bleeding "due to Aspirin and Plavix ...patient had voice understanding." Patient was taken to surgery at 11:12 am, and at approximately 11:55 am, patient was transported to the PACU for recovery. At 11:44 am, while in the OR the EMR reflected the surgical incision had "approximated edges, steri-strips, band aid, C/D/I (clean/dry/intact). At 11:54 am, EMR showed "scant drainage, band aid, steri-strips, intact". At 1:18 pm, EMR showed "large sanguineous (blood) red drainage, C/D/I (with comment "dressing changed")". Patient was discharged home at 1:42 pm. The EMR showed no additional documentation including but not limited to:
*Documentation of assessment of the surgical incision when the patient was transferred from the PACU and transferred back to the pre-operative area.
*Documentation of a nursing assessment for any additional changes in the patient's physical condition after the large bleed was recognized and prior to discharge.
*Notification of the physician regarding the increased bleeding
*Outcome of physician notification including any additional orders/instructions and physician approval to discharge the patient.

On 04/01/18 at 2:43 pm, Staff I stated he/she would notify the surgeon if a patient had increased bleeding from the surgical site. Staff I stated he/she was "not sure" where he/she would document the discussion with the surgeon in the EMR. Staff I stated the nursing notes section in the patient's EMR "would be an option for us to document that we notified the doctor".

On 04/11/18 at 12:52 pm, Staff F stated he/she would assess surgical incision(s) and dressing(s) when the patient arrived in PACU, right before the patient leaves PACU, on arrival to Phase II (out-patient area after surgery) and just prior to discharge. Staff F stated "I don't necessarily chart if the dressing was the same as it was previously". Staff F stated Patient #2's dressing had a "scant amount of drainage on it until when we sat the patient up to get dressed to go home." Staff F stated when he/she sat Patient #2 up to get dressed he/she saw the blood going down his/her side and he/she called the team leader in to help. Staff F stated the blood was on the bed and sheets and he/she had to wet a "few washcloths and it covered the washcloths but did not soak them". Staff F stated he/she noted some blood clots in the drainage. Staff F stated Staff B (Director of Surgery) was there and he/she notified Staff A (surgeon) regarding Patient #2's increased bleeding at the surgical site. Staff F stated he/she the surgeon had said increased bleeding was to be expected due to the Plavix and Aspirin, and this could happen again. Staff F stated the surgeon instructed him/her to notify the family if they were unable to stop the bleeding by holding pressure to return to the ED.

III. Vital Signs

Review of hospital policy titled "Post Anesthesia Care Unit" showed vital signs were to be taken and documented every 15 minutes.

Review of hospital policy titled "PACU Admission Protocol" showed vital signs should be taken every five minutes and documented in the EMR.

Patient #1 was a 56 year old who presented to the hospital for a laparoscopic cholecystectomy secondary to calculus of the gallbladder and acute on chronic cholecystitis. Patient arrived at the hospital on 04/09/18 at 9:52 am, initial vital signs included temperature of 97.0, heart rate 77, respirations 18 and a blood pressure of 218/106 at 10:02 am. There was no evidence in the EMR the CRNA (certified registered nurse anesthetist), anesthesiologist or surgeon were notified. The patient was taken to the OR at 10:21 am, while in the OR the patient was given 15mg of Hydralazine (antihypertensive agent) intravenously (IV) in three divided doses to lower the patient's blood pressure because the patient's systolic (the amount of pressure in the arteries during the contractions of the heart muscle) blood pressure was greater than 200 mmHg.

On 04/10/18 at 2:43 pm, Staff I stated he/she would notify the anesthesiologist in the OR if a patient had an elevated blood pressure prior to surgery.

On 04/11/18 at 12:52 pm, Staff F stated he/she would text the anesthesiologist and notify him/her of significantly elevated blood pressures prior to the patient "going back for surgery".

Based on record review and interview the hospital failed to ensure pain was managed and documented for one (Patient #31) of a total sample of 20 medical records reviewed pre-operatively per hospital policy.

Findings:

Review of hospital policy titled "Pain Management" showed a patient's report of pain was enough evidence to support a need for intervention. A numeric 0-10 pain scale was used to assess, document and evaluate patient's pain and relief measures. A rating of four and greater or an unacceptable level identified by the patient required intervention. Scores four and greater or at an unacceptable identified by the patient on reassessment required notification of the physician.

Review of hospital policy titled "Post Anesthesia Care Unit" showed patient should be assessed for pain and given pain medication as prescribed.

Patient #1 was a 56 year old who presented to the hospital for a laparoscopic cholecystectomy secondary to calculus of the gallbladder and acute on chronic cholecystitis. Patient arrived at the hospital on 04/09/18 at 9:52 am, and was taken to surgery at 10:21 am. Patient was assessed for pain at 10:02 am, and patient reported acute abdominal pain of 10/10 on the numeric pain scale. There was no evidence of documentation in the patient's EMR the surgeon or anesthesiologist was notified of the patient's pain or intervention for severe pain per hospital policy.

On 04/10/18 at 2:43 pm, Staff I stated pre-operatively patients "cannot receive pain medications prior to seeing the surgeon and the anesthesiologist". Staff I stated when patients have pain, nursing staff would call back into the OR and talk to the anesthesiologist to request orders for a pain medication pre-operatively.

Based on record review, interview, and observation, the Infection Control Preventionist failed to ensure the disinfection / sterilization practices for endoscopes, endoscope accessories, and liquid chemical sterilant processing systems (Steris System 1E) were according to manufacturer's guidelines and national standards.

These failed practices had the potential to result in inadequate cleaning and disinfection / sterilization of instruments and equipments, and to increase the risk cross contamination to the patients receiving endoscopic procedures.

Findings:

I. Endoscopes and Endoscope accessories

A. Pre-cleaning Enzyme

A review of guidelines titled, "CDC Guidelines for Disinfection and Sterilization in Healthcare Facilities (2008)" documented enzyme solutions should be used in accordance with manufacturer's instructions, which included the proper dilution of the enzymatic detergent.

A review of the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15) showed all scopes were to be cleaned with approved enzymatic cleaner after each use, but failed to refer to the enzyme's manufacturer's instruction for use.

A review of the manufacturer's guidelines titled, "Ruhoff Endozime Bio-Clean" documented the enzyme should be diluted ½ ounce to 1 ounce per one gallon of water.

On 04/09/18 at 12:22 pm, Staff K, who was responsible for endoscope pre-cleaning, was unable to communicate the manufacturer's recommended dilution of enzyme. Staff K stated a couple of "pumps" from the enzyme dispenser was used in the pre-cleaning water.

On 04/09/18 at 12:22 pm, the surveyor observed Staff K reprocess an endoscope in simulation.

B. Auxillary Water Tube (MAJ-855)

On 04/10/18 at 10:20 am, surveyor requested endoscopic reprocessing policies, and the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15)" was provided. The policy failed to refer to manufacturer's guidelines, and provided no instructions regarding the use and disinfection of Auxillary Water Tube (MAJ-855) (a one way flow protection valve) .

A review of Olympus reprocessing manual for endoscopes (180 series) showed the auxillary water tube should be placed between the endoscope and the endoscopic flushing pump tubing, and needed to be cleaned, disinfected, or sterilized prior to its use in any patient procedure.

On 04/09/18 at 12:22 pm, Staff K stated staff did not use Auxillary Water Channel Adaptor (MAJ-855).

On 04/09/18 at 12:22 pm, surveyor observed the tubing of the endoscopic flushing pump was connected directly to the endoscope's auxillary inlet and MAJ-855 was not used. Staff K located plastic bag containing numerous MAJ-855 tubes on a shelf.

C. Adenosine triphosphate (ATP) Testing

On 04/10/18 at 10:20 am, surveyor requested endoscopic reprocessing policies, and the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15)" was provided. The policy provided no instructions for (ATP) Testing.

A review of FDA procotol titled, "Duodenoscope Surveillance Sampling and Culturing Protocols" showed "Rapid ATP Testing: Residual adenosine triphosphate (ATP) on cleaned reusable medical devices has been used as a marker of an inadequate cleaning process. Detection of ATP after cleaning of a medical device may represent residuals from patient secretions (as human cells and secretions have high ATP levels), as well as residuals from bacteria (bacteria have low ATP levels and high numbers of bacterial cells are required to elicit a positive ATP reading). Cleaning is expected to remove both patient-derived secretion and patient-derived bacteria."

A review of the manufacturer's instructions for use titled, "Endoswab" showed sample collections would be done after the cleaning of reusable medical instruments to ensure cleaning procedures were effective.

On 04/09/18 at 12:22 pm, Staff B and Staff K stated ATP testing was performed on 100% of endoscopes after the disinfection process (not after the pre-cleaning process).

II. Liquid Chemical Sterilant Processing Systems (Steris System 1E)

A. Storage after use

A review of the manual titled, "Steris System 1 instruction for use" showed on page i,, "After completion of a cycle ...the processed load should be used immediately". (The final cycle of this type of reprocessor does not flush air, alcohol, and air to reduce the risk of water borne bacteria contamination. Endoscopes reprocessed by this equipment, if stored, would not considered ready for use.)

A review of the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15)" documented "Use immediately before the procedure or autoclave. Flexible scopes ... [endoscopes] are processed with Steris 1 [Steris System 1E] immediately after use and stored in a clean cabinet."

On 04/09/18 at 12:22 pm, Staff B and Staff K states endoscopes were processed by Steris System 1E and stored in a cabinet.

On 04/09/18 at 12:22 pm, the surveyor observed multiple endoscopes hanging in a storage cabinet that were identified as ready for use.

B. Filter Change Logs

A review of the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15) showed no instructions regarding Steris System 1E filter change frequency and documentation.

A review of the manual titled, "Steris System 1 instruction for use" showed four types of filters were to be changed at identified intervals.

On 04/09/18 at 1:46 pm, Staff M stated he/she labeled the filter canisters with the date the filters were changed, but did not maintain a permanent record showing evidence of the changes.

On 04/09/18 at 1:46 pm, surveyor observed Steris System 1E filter canisters labeled with dates.

C. Chemical Strip

A review of the policy titled, "Steris 1 Processing Rigid and Flexible Scopes (date 10/15) showed no instructions regarding Steris System 1E chemical strip documentation of lot numbers and expiration dates.

On 04/09/18 at 1:46 pm, Staff M stated when a chemical strips bottle was opened, Staff would write the date on the bottle's label. Staff M stated there was no permanent documentation of the chemical test strips's lot number and expiration for newly opened bottle.

Based on record review and interview, the hospital failed to ensure policies for:

I. (A & B) .Malignant Hyperthermia, Endoscopic Reprocessing, and Steris System 1E were developed and updated to provide guidance for the surgical care services provided that were in accordance with manufacturer's instructions for use.These failed practices had the potential to result in lack of staff knowledge and increased risk for errors in care of surgical services and manufacturers' standards.

II. post-surgical patients were provided discharge instructions that were specific to the patient's needs and surgical procedure(s) and evidence of acknowledgement the patient and/or family received the instructions. This failed practice resulted in the potential delay in seeking additional medical treatment in the ED for one (Patient #2) of a sample of 20 patient medical records reviewed and potentially a delay in recognition of medical conditions that should be treated in the ED for all post-surgical patients.

Findings:

I. A. Malignant Hyperthermia
A review of the policy titled, "Malignant Hyperthermia (date 10/15)" showed "administer Dantrolene Sodium IV [intravenous] as soon as possible" and instructions provided for dosages.

On 04/09/18 at 12:22 am, Staff B stated Dantrolene Sodium was replaced by a medication called Ryanodex due to the cost of Dantrolene.

On 04/09/18 at 12:22 am, surveyor observed the contents of the surgical malignant hyperthermia cart to include Ryanodex.

B. Endoscopic Reprocessing and Use of Steris System 1E ( Refer to A-0749)

II. Post-Surgical Discharge Instructions


Review of hospital policy titled "Education of Family/Significant Other/Patient" showed patient/family education should be understandable and specific to the patient's "relevant health care needs" ...discharge instruction information were to be provided to a responsible individual for the continued care of the patient ...education of patient/family or responsible individual should be documented in patient's EMR including documentation of educational information or resources provided.

Review of hospital policy titled "Documentation of Patient Care" showed the purpose of the policy was for the "documentation of patient data and information that supports the safe, timely, and effective care of the patient ..." Data and information related to the patient's education and discharge instructions should be documented in "complete detail"..."All documentation was to reflect a personalized plan and response for every patient".

Five (Patient #1, 2, 3, 10, and 30) of a total sample of five out-patient medical records showed standardized discharge instructions for surgical procedures. Review of records showed no evidence of documentation to reflect individualized instructions for the specific needs of the patient, including follow up care and appointments. In the EMR there was a statement "Patient/family/caregiver verbalized understanding" for discharge instructions and "yes" or "no" was checked. There was no evidence in the out-patient surgical records the patient "acknowledged" receipt of written discharge instructions as there was in the in-patient records.

On 04/11/18 at 11:53 am, Staff C (team leader) stated Patient #2 was provided additional discharge instructions to hold pressure on the incision site with a pressure dressing, if the bleeding did not stop to notify the physician and if it was an emergency to return to the ED. Staff C stated in the post-operative phone calls staff direct patients to go to the doctor when they have complaints, such as of increased bleeding. Staff C stated this would be documented in the post-operative phone call in the EMR. Staff C stated he/she was not aware if discharge instructions could be individualized in the EMR.

On 04/11/18 at 12:52 pm, Staff F stated Patient #2 "should have been given instructions that the doctor puts in". Staff F stated he/she was not aware if the discharge instructions were able to be changed and additions made to include specific instructions such as provide pressure dressing and hold pressure. Staff F stated he/she had instructed the family increased bleeding was to be expected due to the Plavix and Aspirin and this could happen again, and if they were unable to stop the bleeding by holding pressure to return to the ED. Staff F stated he/she could not find these additional instructions in Patient #2's EMR.
Staff F stated documentation in the EMR to validate the patient had received instructions would be by checking "yes" for the statement "patient/family verbalized understanding".

On 04/11/18 2:42 pm, Staff G stated he/she "thought you could free text in the after visit summary" to include additional instructions that was provided to the patient at discharge.