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Based on interviews and the review of documents, it was determined the facility staff failed to ensure a physician documented the need to perform an emergent procedure without completing an informed consent form for one (1) of six (6) patients sampled for a surgical procedure review (Patient #6).

The findings include:

Review of Patient #6's clinical documentation failed to reveal a completed informed consent form for an "exploration of tonsil fossa, control of postoperative hemorrhage".

Patient #6's clinical documentation included a consult note that was documented as being dictated on 8/28/18 at 2:34 a.m. The following was found documented in this consult note: "IMPRESSION: Postoperative tonsil hemorrhage. Given the repeated nature of the problem, I recommended to the parents that the patient [sic] to undergo exploration of the tonsil fossa for control of postoperative hemorrhage. The procedure was explained. Complications including further bleeding, anesthetic complications were reviewed. (He/She) will be brought to the operating room for exploration once the operating room team can be assembled."

The following information was found in a facility policy titled "Informed Consent" (with a review and/or revision date of 4/17): "The physician must document in the medical record the need to proceed without written consent and the treatment or procedure performed."

During an interview on 10/24/18 at 8:50 a.m., Staff Member (SM) #9 reported no documentation, by the physician, of a need to perform the aforementioned procedure without obtaining a signed consent was found.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure post-procedure evaluations were completed and/or documented in a timely manner for two (2) of six (6) patients sampled for a surgical procedure review (Patient #3 and Patient #6).

The findings include:

1. Patient #6 was discharged from the facility on 8/28/18. Patient #6 had discharge orders entered on 8/28/18 at 3:09 a.m.

Patient #6's clinical documentation included an "Anesthesia Postprocedure Evaluation" documented for the "Date of Service: 08/30/18 (at) 0710 (a.m.)".

The following information was found in a facility policy titled "Discharge Protocol from Post Anesthesia Care Unit - Phase 1" (with a review and/or a revision date of 1/17): "All patients will remain PACU Phase 1 until they have met discharge/transfer evaluation and the anesthesiologist must have completed the assessment for early anesthesia complications and signed the form."

The following information was found in a facility policy titled "Discharge Protocol from Post Anesthesia Care Unit - Phase II" (with a review and/or a revision date of 1/16): "The PACU nurse may discharge a patient from PACU II when the following criteria have been met and anesthesiology has evaluated the patient, for early anesthesia complications and signed the record, unless an anesthesiologist or surgeon has written exception orders."

The failure of the facility staff to have a post-procedure anesthesia assessment completed and signed prior to Patient #6 being discharge was discussed with facility administrative staff at the end-of-day meeting on 10/24/18. This issue was discussed for a final time on the morning of 10/25/18 with facility staff including but not limited to the CEO, a Regulatory Coordinator, and the Director of Quality/Regulations.

This is a complaint deficiency.


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2. The clinical record for Patient #3 was reviewed on 10/24/18 with the assistance of Staff Member (SM) #19, a navigator provided by the hospital. Patient #3 underwent a laparoscopic sleeve gastrectomy with esophagogastroduodenoscopy performed by SM #25, on 10/16/18 under general anesthesia administered by SM #24.

A review of anesthesia encounter notes found an anesthesia preprocedure evaluation was completed by SM #26 on 10/16/18 at 7:57 a.m.. The anesthesia postprocedure evaluation was documented as occurring 10/20/18 at 9:22 a.m. by SM #26. The navigator assisting the surveyor with the chart review (SM #19) was unable to find any earlier documentation of the postprocedure evaluation and agreed with the surveyor that although postprocedure evaluation may have been completed at an earlier time. The documentation in the clinical record has the evaluation documented as occurring more than four days after the procedure.

The above findings were shared at the time of discovery with SM #19 and again at the end of day meeting on 10/24/18. No further evidence was provided to the survey team.