HospitalInspections.org

Based on medical record review, policy review, and interview, in two of six medical records reviewed, the hospital failed to ensure that nursing staff ambulated patients prior to discharge per physician's order (Patient #9 and Patient #12).

Findings include:

Review of the policy "Admission, Care and Discharge of the Ambulatory Surgery Unit (ASU) Patient," dated 12/01/22, revealed post procedural care patient assessments include patients needing to use the bathroom are escorted to the bathroom and assessed for ability to void and ambulation, and other assessments per provider post-op orders. Document all patient assessments, interventions, and outcomes related to the admission, care of the patient, and discharge on the appropriate section of the electronic medical record.

Medical record review revealed the following cardiac ablation (a procedure that treats irregular heart rhythms, also known as arrhythmias, by using heat or cold to create small scars on the heart tissue) patients had physician orders to be discharged after ambulation, if vital signs were stable, and there were no symptoms of bleeding: Patient #9 on 04/03/25 and Patient #12 on 03/26/25. No documentation of ambulation prior to discharge was found for either patient.

Interview on 06/04/25 at 11:00 AM with Staff (D), Hospital Administrator, verified these findings.