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Based on record review and staff interview, the hospital failed to review and revise the care plan for 3 of 3 restrained, active patients (#9, #10, #17) and 1 of 1 restrained, discharged patients (#1 D/C), in a total sample of 36 active patients and 4 discharge patients.

Findings include:

1. Patient #9 had diagnoses of bipolar disorder, anxiety disorder, mood disorder disorder, and moderate mental retardation.

The patient had treatment plans dated 8/7/12 and 8/24/12.

On 8/4/12 at 13:13 P.M., the patient was restrained with locked door seclusion for threatening and aggressive behavior. A review of the medical record on 10/10/12 revealed that the treatment plan of 8/7/12 was not updated to include the use of restraints.

On 8/15/12 at 21:05 P.M., the patient was restrained with a physical hold after assaulting staff. On 8/22/12 at 12:25 P.M., the resident was restrained with locked door seclusion after being physically aggressive with staff. On 8/22/12 at 12:10 P.M., the patient was restrained with a 5 minute physical hold after physically assaulting staff. The treatment plan of 8/24/12 was not updated to include the use of restraints.

During interview on 10/11/12 at 11:05 A.M., Registered Nurse (RN) #9 on the psychiatric unit said that the care plan should include the use of restraints.

2. Patient #10 had a diagnosis of an eating disorder.

The patient had treatment plans dated 10/2/12 and 10/9/12.

On 9/30/12, the patient was restrained with locked door seclusion initially, then 4 point soft cuff and a chemical restraint after assaulting mother and staff. The treatment plan dated 10/2/12 was not updated to include the use of restraints.

On 10/4/12, the patient was restrained with seclusion, 5 point restraints and chemical restraint after harming self and others. The treatment plan, dated 10/9/12, was not updated to include the use of restraints.

During interview on 10/11/12 at 11:05 A.M., RN #10 on the psychiatric unit said that the care plan should include the use of restraints.

3. Patient #17 had diagnoses of anorexia nervosa, depressive disorder and anxiety disorder.

The patient had a current nursing care plan.

On 9/15/12, the patient was restrained at 13:04 P.M., with 4 point restraints and physical hold by security after biting, kicking, spitting and punching nursing staff.

On 10/3/12 at 20:10 P.M., the patient was restrained by 4 security guards who held 4 limbs after an incident where the patient was a danger to self and others.

A review of the medical record on 10/9/12 revealed that the current nursing care plan was not updated following either use of restraints. During interview on 10/11/12, RN #14, the Behavior Specialist, stated that the care plan should be updated following the use of restraints.

4. Patient #1 D/C, had diagnoses of eating disorder, depressive disorder and anxiety disorder. The patient was discharged on 5/17/12.

The patient had a current nursing care plan.

On 5/3/12, the patient was agitated and threatened to harm self. The patient was restrained in a physical hold by 3 security guards.

A review of the medical record on 10/15/12 revealed the current nursing care plan was not updated following the use of restraints. During interview on 10/11/12, RN #14, the Behavior Specialist, stated that the care plan should be updated following the use of restraints.

Based on record review and staff interview, the hospital failed to obtain a physician's order for a physical hold for 1 of 3 restrained active patients (#17) and 1 of 1 restrained, discharged patients (#1 D/C), in a total sample of 36 active patients and 4 discharged patients. Also, the hospital failed to obtain an accurate physician's order for a 4 point restraint for 1 restrained active patient (#17).

Findings include:

1. For Patient #17, the hospital failed to obtain: (a) a physician's order for a physical hold by 4 security guards and (b) an accurate order for a 4 point restraint.

The hospital's policy for restraints indicated the following: A restraint is a bodily physical restriction by manual method or mechanical device that limits the patient's ability to move arms, legs, head, or body.

a) On 10/3/12 at 20:10 P.M., the patient was restrained by 4 security guards who held 4 limbs after an incident where the patient was a danger to self and others.

A review of the medical record on 10/9/12 revealed that there was no physician's order for the physical hold.

During interview on 10/15/12 at 11:00 A.M., the Vice President of Patient Relations and RN #14, the Behavior Specialist, indicated that orders would be obtained for physical holds in the future.

b) On 9/15/12, the patient was restrained at 13:04 P.M., with 4 point restraints and physical hold by security after biting, kicking, spitting and punching nursing staff. There was an order for a physical hold but no order for the 4 point restraint.

During interview on 10/11/12, RN #14, the Behavior Specialist, stated that the nurse on duty had made an error on 9/15/12 and had not correctly asked the physician for an order for a 4 point restraint.


2. For Patient #1 D/C, the hospital failed to obtain a physician's order for physical holds by security guards and nursing staff.

Patient #1 D/C had diagnoses of eating disorder, depressive disorder and anxiety disorder. The patient was discharged on 5/17/12.

On 5/3/12, the patient was agitated and threatened to harm self. The patient was restrained in a physical hold by 3 security guards.

A review of the medical record revealed that there was no physician's order for the physical hold.

During interview on 10/15/12 at 11:00 A.M., the Vice President of Patient Relations and RN #14, the Behavior Specialist, indicated that orders would be obtained for physical holds in the future.

Based on record review and staff interview the hospital failed to ensure that patient nursing care plans were kept current by ongoing assessments of the patient's needs and the patient's response to interventions, and updating or revising the patient's nursing care plan in response to assessments for 8 patients (#4, #5, #8, #11, #14, #16, #18 and #24), in a total sample of 36 inpatients.

Findings include:

1. Patient #4 was admitted 7/9/12 with diagnoses including acute myeloid leukemia.

Review of the current Plan of Care (POC) listed only patient problems and goals but no specific interventions to address identified problems. For example, patient goals were listed as follows: learning needs of health, risk factors for infection, hemodynamics will be stable and other potential side effects of chemotherapy.

There were no nursing interventions identified to meet these identified problems and goals.

2. Patient #5 was admitted 10/01/12 with diagnoses including acute lymphoblastic leukemia.

Review of the current POC listed patient goals but no specific interventions to address identified problems. For example, patient goals were listed as follows: optimal neurological function will be exhibited and baseline age appropriate development will be maintained.

There were no nursing interventions identified to meet these identified goals.

3. Patient #11 was admitted 9/23/12 with diagnoses including sickle cell anemia and severe sinusitis.

Review of the current POC listed patient goals but no specific interventions to address identified problem areas. For example, patient goals were listed as follows: optimal neurological function will be exhibited prior to discharge and treatment of infection will be effectively managed.

There were no nursing interventions identified to meet these identified goals.

4. Patient #14 was admitted 8/26/12 with diagnoses including congenital lymphatic malformation and right sided chylothorax (a type of pleural effusion).

Review of the current POC listed patient goals but no specific interventions to address identified problem areas. For example, patient goals were listed as follows: adequate gas exchange will be maintained, pain and side effects of sedation/analgesia will be controlled, risk factors for chest tube will be reduced and fluid and electrolyte balance will be adequate.

There were no nursing interventions identified to meet these identified goals.


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5. For Patient #16, the Hospital failed to plan nursing interventions for problems identified on the nursing assessment.

Patient #16 was recently admitted for respiratory failure and had previously underwent open heart surgery for Tetralogy of Fallot repair in 6/2012. The patient also had multiple other congenital birth defects such as cleft lip and palate requiring naso-gastric feeding only, right nares not patent, hip dysplasia requiring hip brace bilaterally, hypothyroidism, butterfly vertebrae, brain and skull abnormalities with suspected cognitive deficits.

The nursing assessment, completed on 10/9/12, identified problems of lower extremity edema, hip joint pain related to bilateral hip dislocations requiring the use of a hip brace 24 hours a day, which also put skin at risk for breakdown, and nursing also noted the child comforted with swaddling and a pacifier.

Review of the multidisciplinary POC indicated goals to meet medical needs were established to include: adequate gas exchange will be maintained with interventions to provide a high-flow nasal cannula, chest therapy and nasal-pharyngeal suctioning; equalizer treatment as scheduled or needed; risk factors for infection will be reduced (however, no risk factors were identified and no specific nursing interventions were identified); hemodynamics will be stable (but no nursing interventions were identified); and pain and side effects of sedation and analgesia will be controlled (again with no nursing interventions identified).

Although nursing identified potential issues with lower extremity edema, hip joint pain and brace use for hip dislocation 24 hours a day, potentially affecting comfort and skin, there were no nursing interventions developed to address these areas to lessen the potential complications.

During observation of Patient #16 on 10/10/12, between 9:30 A.M. and 11:30 A.M., the child lay quietly in a dark room in the crib without crying, from 9:30 A.M. to 11:15 A.M., and no staff were observed to enter the room. At 11:15 A.M., the surveyor and R.N. #4 entered the room and found the patient awake and alert. The patient interacted with the surveyor by playing with the surveyor's gloved hand and seeking eye contact. There was no mobile above the patient's bed and a small red stuffed animal was noted in the crib. The blinds were pulled and the room was very dark. The patient was observed to have a hip brace on that encircled both hips but was open between the legs where the diaper sat. The brace fit tightly against the inside of the folds of the thighs.

During an interview, R.N. #4 said she removes the brace once a shift and checks the skin for breakdown and cleans the skin. R.N. #4 said there was no nursing POC or physician order on how to manage the patient's brace and skin so she was not sure what other staff were doing to be consistent in the care and observation of the brace and skin. R.N. #4 said this was her first day caring for the patient.


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7. For Patient #8, medical record review on 10/9/12, indicated the following POC goals were established: hemodynamics (e.g. blood pressure, heart rate, respirations) will be stable; skin integrity and healing will be maintained; diet and nutrition will advance as tolerated; fluid and electrolyte balance (i.e., intake and output) will be adequate; pain an side effects of sedation/analgesia will be controlled; understanding of medications will be verbalized; and baseline age appropriate development will be maintained.

Continued medical record review indicated that the POC lacked individualized nursing interventions to achieve the above identified goals. In addition, the patient had a lower back tumor removed on 10/8/12, however, a goal for prevention of infection was not identified.

In an interview with RN #18 at 10:30 A.M. on 10/9/12, the RN said that the prevention of infection should have been included as a nursing goal.

8. For Patient #24, a patient with a central intravenous (IV) line, a feeding tube (through the skin into the stomach), and a tube though the skin into the liver, medical record review on 10/9/12 indicated the following POC goals were established: hemodynamics (e.g. blood pressure, heart rate, respirations) will be stable; diet and nutrition will advance as tolerated; fluid and electrolyte balance (i.e., intake and output) will be adequate; and laboratory tests will be stable.

Continued medical record review indicated that the POC lacked individualized nursing interventions to achieve the above identified goals.

In an interview with RN #9 at 4:00 P.M. on 10/9/12, the RN said that skin integrity for this patient was a big issue, along with the parents' knowledge deficit regarding the patient's care. The RN said that these problems should have been identified along with goals and interventions for addressing the problems.

Based on observation of refrigerator temperatures and review of the Refrigeration Temperature Monitoring Policy, the Hospital failed to ensure that refrigerated food was stored in accordance with nationally accepted guidelines.

Findings included:

1. On 10/9/2012, the surveyor observed refrigerators and freezers in the Main Kitchen and in five nourishment kitchens on the Boston Campus. The Surveyor observed and staff confirmed that the refrigerators were equipped with a monitoring device to send a text alert to the 24 hour/7 day per week Operations Center when an out-of-range refrigerator temperature is detected.

On 10/10/2012, the surveyor observed refrigerators and freezers in the Main Kitchen and in the nourishment kitchen on the Waltham Campus. One refrigerator in the Main Kitchen that contained hard cooked eggs and cheese had no thermometer. At surveyor request, the cook checked the temperature of the hard cooked eggs. The eggs registered 48 degrees F. Potentially Hazardous Foods under refrigeration must be maintained at 41 degrees F or less. As a result of the high temperature reading, staff discarded the eggs and cheese.

2. On 10/10/2012, the surveyor reviewed Hospital Policy #234: "Refrigeration Temperature Monitoring". The policy read that the temperature of each refrigerator and freezer used for the the storage of patient food or breastmilk is continuously monitored to assure appropriate temperature control. The policy further read that the acceptable temperature range for the refrigerators is between 1 degree Celsius (C) to 5 degrees C or 33 degrees Fahrenheit (F) to 46 degrees F. According to the United States Food & Drug Administration 2009 Food Code and the Serve Safe Guidelines, potentially hazardous foods under refrigeration must be maintained at 41 degrees F or less.

3. On 10/11/2012, the surveyor informed the Food Service Department Director that the "Refrigeration Temperature Monitoring Policy" for acceptable refrigerator temperatures did not comply with nationally accepted standards for holding potentially hazardous foods under refrigeration at 41 degrees F or less.

4. On 10/15/2012 at 11:15 A.M., the Hospital provided a revised "Refrigeration Temperature Monitoring Policy" to the surveyor. The revised policy read that "refrigerator temperatures are maintained between 1 degree C to 5 degrees C or 33 degrees F to 41 degrees F", which complies with the nationally accepted standards.

Based on observations, interviews, and review of the Hospital's policies/procedures and logs, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.

Findings include:

A. The Hospital failed to ensure that a high level disinfection (HLD) process (a cleaning process that should destroy all microorganisms, except for bacterial spores) was consistently used to reprocess semi-critical items (items that contact mucous membranes or non-intact skin) at the satellite located at Boston Children's Hospital at Waltham, 9 Hope Avenue, Waltham, MA.

The following steps in the disinfection process were not performed in accordance with manufacturer's instructions:

1. Observations in the soiled utility room of the Otolaryngology (OTL) clinic on 10/11/12 at approximately 11:10 A.M. revealed manual high level disinfection using an OPA product (ortho-phthalaldehyde) was used to reprocess the OTL scopes (an optical instrument that is inserted through a patient's nose and assists the physician in the examination of the larynx).
In accordance with the manufacturer's instructions, the temperature of the disinfectant and the MEC (minimum effective concentration) dipstick test must be completed with each cycle to ensure the minimum temperature and adequate chemical concentration was achieved. Interview with the OTL technologist (OTL tech #1) revealed that the high level disinfectant was tested only once daily and not with each use as directed by the manufacturer.

B. The hospital failed to consistently follow its policy for immediate-use sterilization, an abbreviated cycle of sterilization for surgical items that are required on short notice (formerly know as "flash sterilization") at the satellite located at Boston Children's Hospital at Lexington 482 Bedford Street, Lexington, MA.
Observation of the immediate-use sterilization logs, and review of the hospital policy entitled "Immediate Use Sterilization of Instruments and Implants 12-8-11" on 10/11/12, revealed immediate-use sterilization was used to reprocess surgical instruments. According to the hospital policy, the Registered Nurse (RN) completes all areas on the immediate use log sheet (i.e. the patient's name, the general contents of the load and the signature of the operator). However, review of the immediate-use documentation indicated the satellite was not using the log and was lacking documentation of the patient's name, what instrument(s) underwent immediate-use, and validation that the parameters for the immediate-use cycle had been met.
C. The hospital failed to consistently follow the manufacturer's instructions for use in monitoring the sterilization process of the Steris 1E sterilizer.
Observations in the Central Processing Department (CPD) on 10/10/12 at approximately 07:30 A.M. revealed a Steris 1E was used to reprocess semi-critical items (items that contact mucous membranes or non-intact skin), i.e. laryngoscope blades (an instrument used to visualize the patients larynx).
In accordance with the manufacturer's instructions, an indicator strip is used for each cycle (the chemical indicator is a peracetic acid concentration indicator for routine monitoring of the system). Per the manufacturer, the strips are opened, dated and used for six months. However, the indicator strips had been opened and not dated, therefore the operator was unable to determine the expiration date.
D. The hospital failed to consistently adhere to OSHA's Bloodborne Pathogens Standard and the hospital's Bloodborne Pathogen Exposure Control Plan.
According to CFR 1910.1030(c)(1)(iv), employers are required to conduct an annual review and update of the Exposure Control Plan to reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens and document annually their consideration and implementation of appropriate commercially available and effective safer medical devices.
Observation in the Ambulatory Surgical Areas at the satellites located at Boston Children's Hospital at Waltham (9 Hope Avenue Waltham, MA) and at Boston Children's Hospital at Lexington (482 Bedford Street, Lexington, MA) on 10-11-12 in the morning, revealed boxes of #16, 18, 20, 22, 23, 25, 27 and 30 gauge non-safety needles readily available for use.

The hospital failed to specify the circumstances in which sharps injury prevention technology may be excluded and non-safety sharps allowed (e.g., device interfered with medical procedures, the safety feature did not promote employee or patient safety). There was no documentation in the hospital's waiver process to support the continued use of select items lacking sharps injury prevention technology.

E. The hospital failed to provide adequate provisions for lactating mothers to comply with infection control standards when cleaning/disinfecting lactation equipment.

Observation in the Lactation Room and interview with the Lactation Support Nurse on 10/9/12 at approximately 11:40 A.M., indicated that the hospital provided lactating mothers with breast pump tubing. According to the Lactation Support Nurse, mothers were instructed to use the lactation room pump. After using the breast pump and tubing the mothers would clean the equipment in the handwashing sink of the Lactation Room or in their child's room. The mothers were then instructed to microwave the tubing as directed by the manufacturer's instructions.

However, the breast pump tubing was cleaned in the handwashing sink of either the Lactation Room or the child's room instead of a utility sink designed to clean equipment. Also, the microwave used to disinfect tubing was located in the family waiting area and used by visitors to heat food and beverages and was not dedicated to cleaning/disinfecting of equipment.

F. The hospital failed to provide an adequate environment for invasive Cardiac Catherization procedures.

Observation in the Cardiac Catherization Laboratory Room "A" on 10/10/12 at approximately 2:00 P.M. revealed an open wall drain in the procedure room. According to the Nurse Director, the wall drain was previously used in conjunction with a particular piece of equipment that had not been used "for years". The wall drain did not communicate with any faucets to allow regular flushing of the drain to prevent odors or possible microorganism growth. The wall drain was within six feet of the procedure table.

Based on record review and interview, the Hospital failed to ensure that 2 of 9 Outpatients (#4, #7) had a History and Physical (H & P) that was updated to include any changes in the patient's condition, within 24 hours prior to surgery, or a procedure requiring anesthesia services.

Findings included:

1. For Outpatient #4, a Same Day Surgery (SDS) patient, medical record review on 10/11/12, indicated that the hospital failed to ensure that the H&P that was completed on 9/25/12 was reviewed and that the patient was examined within 24 hours prior to surgery on 10/11/12, as required.

According to Hospital policy, a Procedure Plan/Review form was to be completed and documented within 24 hours after admission or registration and prior to surgery.

The Procedure Plan/Review form read as follows:

"I, the attending surgeon/designee, have reviewed the History and Physical Examination documented on the Pre Anesthesia Evaluation Form (PAEF). The History and Physical has been completed within 30 days of this procedure. Any noted changes are documented electronically on the PAEF or below. This patient has been evaluated during the immediate pre-operative period and the planned procedure is still indicated."

In an interview with the Surgeon in Chief, at 1:35 P.M. on 10/15/12, the Surgeon in Chief said that the Procedure Plan/Review form needed to be completed by the attending surgeon/designee prior to a surgery being performed. The Procedure Plan/Review form for SDS Patient #4 was blank.

In an interview with Physician #1 on 10/11/12 at 2:20 P.M. in the Endoscopy Procedure Room, the Physician said that he had not yet completed the Procedure Plan/Review form. However, the patient had already been medicated, was receiving sedation from an Anesthesiologist, and the Physician was in the process of performing the procedure.

2. For Outpatient #7, a SDS patient, medical record review on 10/15/12 indicated that the Procedure Plan/Review form was not completed by the attending surgeon/designee prior to the patient's surgery. The patient's surgery was completed and the patient had been discharged from the hospital. Although required, the surgeon failed to update the patient's history and physical prior to surgery.

Based on medical record review and staff interviews, the Hospital failed to ensure that all operative reports contained information that described the techniques, findings and tissues removed or altered for 2 of 9 outpatient surgical patients (#6, #7) and 2 of 36 inpatients (#7, #23) from a total sample of 45 patients.

Findings included:

1. For Same Day Surgery (SDS) Patient #6, an outpatient, review of the operative note on 10/15/12 indicated that it lacked a description of techniques, findings and tissue altered, although required. Under the section labeled "Findings" the surgeon only documented "dry AU" (right ear).

In an interview with the Associate Chief of Surgical Services for Nursing at 9:50 A.M. on 10/15/12, the Associate Chief acknowledged the above finding.

2. For Outpatient SDS Patient #7, review of the operative note on 10/15/12 indicated that it lacked a description of techniques, findings and tissue altered, although required. Under the section labeled "Findings" the surgeon only documented "hernia sac."

3. For Inpatient #7, medical record review on 10/9/12, indicated that the record lacked an operative report written immediately after surgery.

4. For Inpatient #23, medical record review on 10/9/12 indicated that the record lacked an operative report with a description of techniques, findings and tissue altered, although required. Under the section labeled "Findings" the surgeon only documented "patent efferent limb."

In an interview with Registered Nurse (RN) #9, at 4:00 P.M. on 10/15/12, the RN said that the findings, techniques, and tissue altered were not documented.

Based on medical record review and staff interviews, the Hospital failed to ensure that 3 of 5 Same Day Surgery (SDS) Patients (#5, #6, #7) who received general, regional or monitored anesthesia, from a total sample of 45 patients reviewed, had a complete intraoperative anesthesia record.

Findings include:

1. For SDS Patient #5, medical record review on 10/15/12 indicated that the record only contained an Anesthesia Short Report (ASR). The ASR did not contain timed-based documentation of vital signs as well as oxygenation parameters.

2. For SDS Patient #6, medical record review on 10/15/12 indicated that the record only contained an ASR. The ASR did not contain patient position, name and amounts of IV fluids, or timed-based documentation of vital signs as well as oxygenation parameters.

3. For SDS Patient #7, medical record review on 10/15/12 indicated that the record only contained an ASR. The ASR did not contain patient position, name and amounts of IV fluids, or timed-based documentation of vital signs as well as oxygenation and ventilation parameters.

4. In an interview with the Chief of Anesthesia on 10/15/12 at 12:10 P.M., the Chief of Anesthesia said the complete anesthesia record was not immediately available for review by Nursing or non-anesthesia staff for 24 hours. The only intraoperative anesthesia documentation that was available to all non-anesthesia staff was the incomplete short form.

The Chief of Anesthesia said that the full anesthesia record could not be printed until the case was closed out, which took 24 hours.

Based on record review, the Hospital's anesthesia service failed to document sufficient information to determine the patient's response to care in the post-anesthesia evaluation, within 48 hours after surgery or a procedure requiring anesthesia, for 6 patients (#1, #7, #8, #15, #22, #23) in a sample of 36 inpatients reviewed. Findings included:

1. Review of the Hospital's policy for documentation of the post-anesthesia note on 10/11/12, indicated that the elements of a post-anesthesia evaluation included: respiratory function, including respiratory rate, airway patency, and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; and postoperative hydration.

2. For Patient #7, medical record review on 10/9/12 indicated that the post-anesthesia note, documented on 10/9/12, only read, "No reportable events related to anesthetic." The note failed to document the required elements of respiratory function, including respiratory rate, airway patency, and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; and postoperative hydration, per Hospital policy.

3. For Patient #8, medical record review on 10/9/12 indicated that the post-anesthesia note, documented on 10/9/12, only read, "No reportable events related to anesthetic." The note failed to document the required elements of respiratory function, including respiratory rate, airway patency, and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; and postoperative hydration, per Hospital policy.

4. For Patient #23, medical record review on 10/9/12 indicated that the post-anesthesia note, documented on 10/9/12, only read "Appropriate mental status, No reportable events related to anesthetic." The note failed to document the required elements of respiratory function; cardiovascular function, including pulse rate and blood pressure; temperature; pain; nausea and vomiting; and postoperative hydration, per Hospital policy.


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5. For Patient #1, who had general anesthesia for a CT and echocardiogram on 9/27/12, the post-op anesthesia evaluation was completed on 9/28/12, which was post-op Day 1. The note said "patient seen and chart reviewed, patient just extubated, looks well, status post increasing diuresis today, no apparent anesthesia complications."

The evaluation failed to assess the required elements per the anesthesia policy and procedure.

6. For Patient #15, who underwent a surgical repair of the aortic valve on 9/25/12, the post-anesthesia note, dated 9/26/12, failed to evaluate the required areas as per the anesthesia policy and procedure for post-anesthesia evaluations. The post-anesthesia evaluation said "patient seen and chart reviewed, events from last night noted and reviewed".

7. Patient #22 had major open heart surgery on 10/8/12 for repair of ventral and atrial septal defects, transposition of the great vessels, closure of patent ductus arteriosus and recreation of ventricles.

Record review on 10/10/12 at 1:00 P.M., indicated there was no post-anesthesia evaluation in the record.