HospitalInspections.org

Based on record review and interview the facility failed to ensure staff document information was provided if the patient did not have an advanced directive, in 7 of 10 medical records reviewed (2, 3, 4, 5, 6, 8, and 9); and failed to ensure staff document if the patient had an advanced directive in 2 of 10 medical records reviewed (1 and 7) . This deficiency directly affects Patients 1, 2, 3, 4, 5, 6, 7, 8 and 9.

Findings include:

Per review of facility policy titled Advance Directives, #HIM 1007, reviewed 1/17, revealed under Procedure: 1. b. "If patient's response is "no", i. a note will be made in the EMR (Electronic Medical Record). A consultation for Social Services will be offered if the patient requests information."

Patient #1's medical record review on 11/13/17 at 12:18 PM revealed there is no documentation the patient was asked if they had an advanced directive.

Patient #2's medical record review on 11/13/17 at 12:58 PM revealed Patient #2 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #3's medical record review on 11/13/17 at 1:04 PM revealed Patient #3 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #4's medical record review on 11/13/17 at 1:22 PM revealed Patient #4 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #5's medical record review on 11/13/17 at 1:32 PM revealed Patient #5 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #6's medical record review on 11/13/17 at 1:36 PM revealed Patient #6 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #7's medical record review on 11/13/17 at 1:42 PM revealed there is no documentation the patient was asked if they had an advanced directive.

Patient #8's medical record review on 11/13/17 at 1:50 PM revealed Patient #8 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

Patient #9's medical record review on 11/13/17 at 2:00 PM revealed Patient #9 did not have an advanced directive, there was no documentation information on completing an advanced directive was offered.

The above deficiencies were confirmed in interview on 11/13/17 during the time of record review between 12:18 PM and 2:05 PM, with Director of Women's Health C, who agreed there should have been documentation of asking about advanced directives and if information was provided.

Based on record review and interview the facility failed to ensure there are comprehensive post anesthesia notes for patients that receive anesthetics, in 2 of 4 patient's medical records that received epidurals (4 and 8), out of a total 10 medical records reviewed. This deficiency directly affects patients 2 and 4.

Findings include:

Per review of facility policy titled Documentation of Anesthesia Care, #ANE 1627, reviewed 1/17, revealed under III. Postanesthesia: After completing the initial assessment and confirming the patient is stable, the anesthesia professional and PACU (Post Anesthesia Care Unit) should conduct a handoff report...D. Anesthesia a. Type of anesthesia (airway management concerns, analgesia management plan, antiemetics, time of last and next dose of antibiotic, other medications, intake/output, relevant labs, vital signs and monitoring trends, patient-specific procedure and hemodynamic considerations, time of report, patient status, oxygen/mode, airway...)

Patient #2's medical record review on 11/13/17 at 1:04 PM revealed an epidural (a catheter placed in the spinal area for alleviating pain in labor) was placed on 4/15/17 while the patient was in labor. There is no documentation of a post anesthesia note related to the epidural.

Patient #8's medical record review on 11/13/17 at 1:50 PM revealed an epidural was placed on 7/17/17 while the patient was in labor. There is no documentation of a post anesthesia note related to the epidural nor documentation of the epidural catheter removed.

The above deficiencies were confirmed in interview with Director of Women's Health C on 11/13/17, at time of record review, between 1:04 PM and 1:50 PM, who agreed the post anesthesia notes should have been in the record.