HospitalInspections.org

Based on record review and interview the facility failed to ensure a post operative anesthesia assessment was completed as per facility policy in 3 of 3 medical records reviewed of patients who had surgery (Patient # 1, 5 & 9) out of a total universe of 10 medical records reviewed.

Findings include:

The facility policy titled "Post-Operative Anesthesia Assessment of Patients (AWH)" #7670457 last revised 2/2020 was reviewed. This document revealed "I. A post-anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia. This need not be the same practitioner who administered the anesthesia to the patient. Cannot be delegated, except to another anesthesia provider. II. Evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia services. (The calculation of the 48 hour time frame begins at the point the patient is moved into the designated recovery area). III. Evaluation must occur any time general, regional or monitored anesthesia has been administered. IV. The evaluation must not begin until the patient is sufficiently recovered from the acute administration of the anesthesia to participate in the evaluation, (e.g., answer questions appropriately, perform simple tasks, etc.). V. For those patients who are unable to participate in the post-anesthesia evaluation, a post-anesthesia evaluation should be completed and documented within 48 hours with notation that the patient was unable to participate, as well as the reason for patient's inability to participate and expectations for recovery time if applicable. VI. Post-anesthesia evaluation must at least include: a Respiratory function, including respiratory rate, airway patency, and oxygen saturation. b. Cardiovascular function, including pulse rate and blood pressure. c. Mental Status. d. Temperature. e. Pain. f. Nausea and vomiting. g. Postoperative hydration. VII. The evaluation needs to take place at a time when the patient has "sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation." This determination must be made by the anesthesia practitioner."

Patient #1's medical record was reviewed. On 10/13/2020 Patient #1 went to the operating room to have "burr" holes placed to relieve the pressure in his brain post motor vehicle accident under general anesthesia. The "Post-Op" note on 10/14/2020 at 8:11 AM documented "This patient was unable to participate in the post anesthesia evaluation due to did not go to pt (patient) room due to decreased exposure in relation to pandemic. Reviewed chart, VS (vital signs) and notes."

Patient #5's medical record was reviewed. On 7/2/2020 Patient #5 went to the operating room for closed hip fracture repair under general anesthesia. The "Post Anesthesia Evaluation" was not documented as completed until 7/7/2020 (5 days later). Patient #5 had another surgery on 7/10/2020 and there was no documented "Post Anesthesia Evaluation."

An interview was conducted with Director of Surgery B on 10/28/2020 at 11:15 AM in regards to Patient #5's late post-operative anesthesia note who stated "I agree it is late. It should have been done within 48 hours." In regards to missing post-operative anesthesia note from 7/10/2020 surgery Director of Surgery B stated "I agree with you there is not one documented as completed."

Patient #9's medical record was reviewed. On 7/27/2020 Patient #9 went to the operating room for placement of a tracheostomy and a permanent feeding tube under general anesthesia. The "Post Anesthesia Evaluation" on 7/28/2020 at 1:27 PM documented "This patient was unable to participate in the post anesthesia evaluation due to limited foot traiffic [sic] r/t (related to) infection controle [sic]. Chart reviewed, no noted problems r/t anesthesia."

An interview was conducted with Director of Regulation & Accreditation A on 10/27/2020 who, when asked if anesthesia post evaluations had changed expectations due to the COVID pandemic replied "We have not changed our policy about the post anesthesia evaluation."

An interview was conducted with Director of Surgery B on 10/28/2020 at 11:15 AM in regards to Patient #'s 1 & 5 post-operative anesthesia note. When asked if the facility has instituted changes in post anesthesia evaluations to limit staff traffic due to the COVID pandemic stated "No, I would expect that they (anesthesiologists) would go to the patient floor or wherever they are to do the assessment as per usual."