HospitalInspections.org

I. Based on observation and staff interview, the Critical Access Hospital (CAH) Diabetes Education Coordinator failed to discard outdated patient care supplies. The Diabetes Education Coordinator reported 82 patients participated in the program, and potentially received patient care supplies, in 2011 and approximately 4-10 patients are seen weekly.

Failure to retain current medical supplies for patient care could potentially harm patients by using supplies that the manufacturer determined may be ineffective and/or harmful when.

Findings include:

1. Observation on 2/14/12 at 10:00 AM, revealed a storage cabinet in the office of Staff A, Diabetes Education Coordinator, contained the following outdated products, available for patient use:

a. 1 of 2 FreeStyle Lite blood glucose monitor kits contained glucose test strips with an expiration date of 12/11.

b. 5 of 5 Accu-Chek Aviva blood glucose monitor kits contained outdated glucose test strips. Observation of the test strips revealed 2 bottles with an expiration date of 4/30/11, 2 bottles with an expiration date of 7/30/11 and 1 bottle with an expiration date of 11/30/11.

c. 2 of 3 OneTouch Ultra2 blood glucose monitor kits contained glucose test strips with an expiration date of 6/11.

d. 6 of 6 OneTouch UltraMini blood glucose monitor kits contained outdated glucose test strips. Observation of the test strips revealed 3 bottles with an expiration date of 11/11 and 3 bottles with an expiration date of 10/08.

2. Observation on 2/14/12 at 10:15 AM, revealed the diabetes education storage cabinet in a classroom, contained the following outdated products, available for patient use:

a. 9 of 9 OneTouch Ultra2 blood glucose monitor kits contained outdated glucose test strips. Observation of the test strips revealed 1 bottle with an expiration date of 8/10, 3 bottles with an expiration date of 7/11, and 5 bottles with an expiration date of 11/11.

b. 1 of 1 OneTouch UltraMini blood glucose monitor kit contained glucose test strips with an expiration date of 6/11.

c. 8 of 8 FreeStyle Freedom Lite blood glucose monitor kits contained glucose test strips with an expiration date of 6/11.

d. 10 of 10 FreeStyle Lite blood glucose monitor kits contained glucose test strips with an expiration date of 7/11.

e. 3 of 3 Precision Xtra blood glucose monitor kits contained glucose test strips with an expiration date of 10/07.

f. 2 of 2 True Track Smart System blood glucose monitor kits contained glucose test strips with an expiration date of 12/09.

3. During an interview, at the time of the observation, Staff A reported she did not discard the blood glucose monitor kits based on the expiration date, since the date only applied to the test strips. Staff A reported she removed the outdated test strips prior to giving a blood glucose monitor kit to a patient, and used outdated test strips for demonstration purposes. Staff A further reported the supplies used primarily by herself, but could be accessed by the dietitian in her absence, if a patient needed a blood glucose monitor. Staff A reported this seldom happened. In addition, Staff A acknowledged, in the distant past, nursing staff have occasionally accessed supplies in her absence, for an inpatient.


27303


II. Based on observation, document review, and staff interview, the Emergency Department (ED) nursing staff failed to follow the manufacturer's directions, and documented the shortened expiration date for 2 of 2 opened vials of glucometer test strips. The ED had an average of 240 patients per month.

Failure to document the shortened expiation date of the glucometer test strips could potentially result in ED staff using an outdated test strip on a patient, potentially resulting in the glucometer determining an inaccurate result, and potentially resulting in ED staff not administering the correct treatment to a patient.

Findings include:

1. Observations on 2/13/12 at 10:45 AM during a tour of the Emergency Department (ED) revealed 1 of 1 opened vial of microdot glucometer test strips at the nurses' station. The open vial of glucometer test strips lacked a date indicating when ED staff opened the vial, or the shortened expiration date.

Observations in ED patient room #3 revealed 1 of 1 opened vial of glucometer test strips in the storage drawers. The open vial of microdot glucometer test strips lacked a date indicating when ED staff opened the vial, or the shortened expiration date.

2. Review of the manufacturer's instructions for the glucometer test strips, revealed in part, "Do not use microdot Test Strips more than 3 months after the vial is first opened. Write the discard date on the vial when you first open it."

3. During an interview, at the time of the tour, Assistant Director of Nursing J acknowledged the ED nursing staff failed to document the discard date on the vial of test strips after opening the vial, as required by the manufacturer.

I. Based on observation, document review, and staff interview, surgical services staff failed to document the date they removed 3 of 3 vials of paralytic medications (2 of 2 vials of succinylcholine, 1 of 1 vial of rocuronium bromide) from refrigerated storage in the anesthesia cart. Director of Nursing C stated the surgical services staff performed approximately 10 surgical procedures that involved general anesthesia and use of paralytic drugs per month.

Failure to document the date surgical services staff removed the paralytic medications from refrigerated storage could potentially result in the paralytic medications loosing potency, and surgical services staff using ineffective medications on surgical patients.

Findings include:

1. Observations on 2/14/12 at 7:45 AM, during a tour of the surgical services area, revealed 2 operating rooms. Surgical services staff performed general surgery procedures in 1 operating room, and endoscopy procedures in the other. The general surgery procedures room had 1 anesthesia cart. Observation of the anesthesia cart revealed 2 of 2 vials of Succinylcholine and 1 of 1 vial of Rocuronium bromide stored at room temperature in the anesthesia cart. The vials of Succinylcholine and Rocuronium bromide lacked documentation that showed the surgical services staff removed the vials from refrigerated storage.

2. Review of the manufacturer's documentation for Succinylcholine revealed in part, "Store in refrigerator ... The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

3. Review of the manufacturer's documentation for rocuronium bromide revealed in part, "Upon removal from refrigeration to room temperature storage conditions ... use rocuronium bromide within 60 days."

4. During an interview, at the time of the tour, Assistant Director of Nursing J acknowledged the surgical services staff had failed to document the date they removed the Succinylcholine and Rocuronium bromide from refrigerated storage.

5. During an interview on 2/14/12 at 10:15 AM, Pharmacist K stated, if surgical services staff failed to document the date they removed the paralytic medications from refrigerated storage, the surgical services staff could not verify if the vials had passed the manufacturer's recommended expiration dates for these drugs when stored at room temperature. (Succinylcholine: stable for up to 14 days at room temperature and Rocuronium: use within 60 days)

I. Based on document review, observation, policy/procedure review, and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure their infection control policies and procedures addressed manufacturers' recommendations for the use of SaniMaster 4 to disinfect patient care surfaces; such as patient beds, nightstands, furniture, lab draw stations (arm chair used to steady a patients' arm during blood draws),and nursing equipment. CAH administrative staff reported an average daily inpatient census of 8 patients.

Failure to establish policies/procedures and follow manufacturers' recommendations for the use of a disinfecting solution could potentially result in inappropriate use of the product and possible transmission of infection and communicable diseases to the CAH patients increasing inpatient stays or death.

Findings include:

1. Review of the manufacturers' instructions for the use of SaniMaster 4 revealed in part:

"Disinfection: Remove gross filth or heavy soil. Apply solution with a mechanical sprayer so as to wet all surfaces thoroughly. Allow to remain wet for 5 to 10 minutes and then let air dry". Time needed for disinfection depends on the organism and infection potential.

2. During an observation, on 2/13/12 at 11:15 AM, Housekeeper F demonstrated the terminal cleaning of a patient room. Housekeeper F reported that staff cleaned all rooms with a solution of SaniMaster 4 and water. Housekeeper F demonstrated how staff sprayed the SaniMaster on all patient care surfaces then immediately wiped the surface with a clean cloth.

Housekeeper F reported that she was unaware of the manufacturers' recommendation for leaving the surface wet with the SaniMaster 4 for 5 to 10 minutes, depending on the infection potential. "I have never been educated on how long to leave the equipment wet."

3. During an observation, on 2/14/12 at 1:40 PM, Phlebotomist H (lab personnel responsible for blood collection) performed a blood draw on a patient sitting in a wheelchair. When asked, Phlebotomist H reported that staff was responsible for cleaning all patient care surfaces, between each blood draw, using SaniMaster 4.

Phlebotomist H reported that he/she was unaware of the manufacturers' recommendation for leaving the surface wet with SaniMaster 4 for 5 to 10 minutes depending on the infection potential.

4. During an observation, on 2/13/12 at 2:00 PM, The Director of Therapies (Staff L) sprayed a physical therapy mat with SaniMaster 4 after a patient used the mat; the mat remained wet approximately 1 minute. Staff L did not know the manufacturer ' s recommendations for use required the surface to stay wet for 5 to 10 minutes in order to kill all microorganisms, depending on the microorganisms' infection potential.

5. Review of CAH Environmental Services Policy and Procedure titled "Housekeeping Infection Control Guidelines" revealed the following information, in part.

"Chemicals," reviewed and approved 2/10/12, lacked evidence of guidelines set for the use of SaniMaster 4 and following the manufacturers' recommendation to disinfect patent care surfaces.

"General Procedures/Practice," reviewed and approved 2/10/12, lacked evidence of guidelines set for the use of SaniMaster 4 and following the manufacturer's recommendation to disinfect patent care surfaces.

6. During interview on 2/14/12 at 3:20 PM, Staff C, Infection Control Coordinator, stated the CAHs policies and procedures, related to the use of SaniMaster 4, only spoke to sanitation and not disinfection of patient care surfaces. Staff C said, they needed to change their policy to reflect that they are supposed to disinfect patient care surfaces. According to Staff C, they had not had any hospital-acquired infections that they could attribute to contaminated patient care equipment.



27303


II. Based on staff interview and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure a system was in place for the surgical staff and infection control staff to track patients with a surgical implant for 1 year to determine if the patient developed a surgical site infection. Assistant Director of Nursing J stated the surgical services staff performed approximately 30 surgical procedures per year that resulted in surgical services staff placing a surgical implant in a patient.

Failure to monitor patients with a surgical implant for 1 year could potentially result in a patient developing a surgical site infection, and the infection control staff failing to include the patient in the CAH's surgical site surveillance. Failure to include the patient in the CAH's surgical site surveillance program could potentially result in the CAHs surgical and infection control staff failing to discover potentially correctable trends in surgical site infections, and potentially prevent a patient from developing a surgical site infection.

Findings include:

1. During an interview on 2/14/12 at 7:30 AM, Assistant Director of Nursing J stated, the CAH surgical services and infection control staff followed the Centers for Disease Control and Prevention (CDC) recommendations.

2. Review of the CDC document "Surgical Site Infection (SSI) Event," revised 1/12, revealed in part, "Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure..."

3. Review of the policy "Guidelines for Determining and Classifying Infections Post-Discharge," reviewed 2/14/12, revealed in part, "SURGICAL WOUND INFECTIONS ... Infections not identified in the hospital and occurring WITHIN ONE (1) MONTH of discharge." Further review of the policy revealed the policy did not include the requirement by the CDC to monitor patients where surgical services staff placed a surgical implant for 1 year.

4. During an interview on 2/15/12 at 7:15 AM, Director of Nursing C stated, the CAH infection control staff did not track patients with a surgical implant for 1 year after surgery to determine if the patient developed a surgical site infection.

Based on document review and staff interview, the physicians and physician's assistants working in the Emergency Department (ED) failed to document the time they wrote medical orders for 4 of 4 closed ED patients' (Patients #1, 2, 3, 4, and 5) medical records and 5 of 5 open ED patients' (Patients #6, 7, 8, 9, and 10) medical records. The CAH administrative staff reported an average of 240 patients received treatment in the ED per month.

Failure to document the time a physician or physician's assistant wrote an order for treatment could potentially result in the CAH staff failing to perform a medical test, or treatment, in a timely manner.

Findings include:

1. Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF VIRGINIA GAY HOSPITAL, INC.," approved 12/9/10, revealed in part, "All clinical entries in the patients' medical record shall be accurately dated, time, and authenticated."

2. Review of closed medical records on 2/14/12 at 12:15 PM revealed the following:

a. Patient #1 presented to the ED for treatment on 1/12/12. Review of the Patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for a urine test and x-rays.

b. Patient #2 presented to the ED for treatment on 1/14/12. Review of the Patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, EKG, x-ray, and a CT scan.

c. Patient #3 presented to the ED for treatment on 1/9/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests.

d. Patient #5 presented to the ED for treatment on 1/14/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, urine tests, EKG, and x-rays.

3. Review of open medical records on 2/14/12 at 2:30 PM revealed the following:

a. Patient #6 presented to the ED for treatment on 2/13/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, urine tests, and x-rays.

b. Patient #7 presented to the ED for treatment on 2/13/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, EKG, and an x-ray.

c. Patient #8 presented to the ED for treatment on 2/13/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, x-ray, and a CT scan.

d. Patient #9 presented to the ED for treatment on 2/13/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the order for the physician's assistant to close Patient #9's cut with staples.

e. Patient #10 presented to the ED for treatment on 2/13/12. Review of the patient ' s medical record showed the physician or physician assistant failed to document the time they wrote the orders for blood tests, urine test, EKG, and x-ray.

4. During an interview on 2/15/12 at 2:30 PM, the Director of Nursing acknowledged the medical records lacked documentation of the time the ED physician or physician's assistant wrote the orders. The Director of Nursing also acknowledged the CAH's policy required the physician or physician's assistant to document the time they wrote the orders.

Based on document review and staff interview, the Emergency Department (ED) Physicians and Physician's Assistants failed to write medication orders in the medical records. Additionally, nursing staff failed to write the verbal medication orders, received from the Physicians and Physician ' s Assistants, in the medical records. Problems identified in 4 of 4 closed ED patients' (Patient #1, 2, 3, 5) medical records, and 3 of 3 open ED patients' (Patients #7, 9, and 10) medical records where the patient received medications in the ED. The CAH administrative staff reported an average of 240 patients received treatment in the ED per month.

Failure to document orders for the nursing staff to administer medications could potentially result in nursing staff accidentally administering the wrong medication to the patient, or potentially administering a medication without an order.

Findings include:

1. Review of the policy "POLICY OUTLINING REQUIREMENTS FOR DOCUMENTATION", reviewed 12/2/11, revealed in part, "Documentation Requirements .. Emergency room requirements ... Orders: All [physician and physician's assistant] orders shall be documented.... All orders for treatment shall be in writing."

2. Review of closed medical records on 2/14/12 at 12:15 PM revealed the following:

a. Patient #1 presented to the ED for treatment on 1/11/12. Review of the nurses ' notes revealed Patient #1 received 2 medications during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications that Patient #1 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

b. Patient #2 presented to the ED for treatment on 1/14/12. Review of the nurses ' notes revealed Patient #2 received 2 medications during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications that Patient #2 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

c. Patient #3 presented to the ED for treatment on 1/9/12. Review of the nurses ' notes revealed Patient #3 received 4 medications during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications that Patient #3 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

d. Patient #5 presented to the ED for treatment on 1/14/12. Review of the nurses ' notes revealed Patient #5 received 1 medication during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications Patient #5 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

3. Review of open medical records on 2/14/12 at 2:30 PM, revealed the following:

a. Patient #7 presented to the ED for treatment on 2/13/12. Review of the nurses ' notes revealed Patient #7 received 3 medications during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications Patient #7 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

b. Patient #9 presented to the ED for treatment on 2/13/12. Review of the nurses ' notes revealed Patient #9 received 1 medication during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medication Patient #9 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

c. Patient #10 presented to the ED for treatment on 2/13/12. Review of the nurses ' notes revealed Patient #10 received 6 medications during their stay in the ED. Review of the physician ' s orders showed the physician or physician ' s assistant failed to write orders in the medical record for the medications Patient #10 received. Additionally, the nursing staff failed to write the verbal order received from the physician or physician ' s assistant.

4. During an interview on 2/15/12 at 2:30 PM, the Director of Nursing acknowledged, in these cases, the medical records lacked written physician orders or written verbal orders for the medications administered to the ED patients. The Director of Nursing stated, the physicians and physician's assistants that provided care to the patients in the ED, verbally instructed the nursing staff to administer the medications, and did not write the orders for the medications in the patient's medical records. Additionally, the Director of Nursing stated the nursing staff failed to write the verbal order they received from the physician or physician ' s assistant.

Based on observation, document review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to safeguard confidential information in the electronic medical record (EMR). The CAH administrative staff reported an average daily census of 7 inpatients.

Failure to safeguard computer stored information could result in identity theft and/or unauthorized disclosure of personal and medical information.

Findings include:

1. Review of a document titled "Notification of Patient Rights and Responsibilities," last reviewed 9/29/11, revealed in part " . . . IV. A. The patient has the right to the confidentiality of clinical records . . .."

2. During an interview on 2/14/12 at 10:00 AM, Staff D, Chief Information Officer, and Staff E, Information Technology (IT) Tech, described features of the EMR system, as it related to security. Staff D and Staff E did not know if the software allowed a person to copy and save information out the EMR. Staff D and Staff E reported they would check with the software company to see if this was possible. According to Staff D, facility staff had not completed any email audits to check for potential security breaches, but Staff D had only worked at the facility about 1 month and was not aware if the previous Chief Information Officer had completed any routine audits. At 12:30 PM, Staff D reported the EMR software would allow staff to copy information and save it outside of the record.

a. During an interview on 2/15/12 at 11:30 AM and a follow-up interview at 12:50 PM, Staff C, Chief Nursing Officer, reported the facility lacked a policy specific to security of the EMR. Staff C reported the facility had only used the EMR since February 2011 and continued to use new pieces of the system, to progress toward a paperless record. Staff C confirmed, while the progression continued, they had not developed policies and procedures related to security issues.

b. During an interview on 2/15/12 at 1:20 PM, Staff C and Staff B, Clinical IT, reported they were unsure if the software would allow a user to save a document outside of the record in a readable format. Staff B demonstrated some of the features of the EMR. Observation revealed Staff B accessed reports in an EMR and attempted to save the information in a document outside of the EMR. The software allowed Staff B to save a document outside of the record, which included personal patient information. Staff B and Staff C confirmed, employees could access personal email from facility computer workstations, and was not against CAH policy. Staff B and Staff C further confirmed, any clinical staff person, with access to the EMR system, could attach a saved file from the medical record, to a personal email then send the email outside of the facility. Staff C reported knowledge staff conducting some email audits, related to determining computer virus origins, in the past.

Based on observation, document review and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the Central Scheduling staff had access to 5 of 5 selected surgeons' (Surgeons A, B, C, D, and E) current surgical privileges in the scheduling area. Assistant Director of Nursing J stated the surgical services staff performed approximately 10 surgical procedures per month.

Failure to ensure Central Scheduling staff had access to the surgeons' current privileges could potentially result in the Central Scheduling staff allowing a physician to schedule and perform a surgical procedure the governing body of the CAH did not authorize the surgeon to perform at the CAH.

Findings include:

1. Observations, during a tour of the Central Scheduling department, on 2/15/12 at 8:00 AM revealed the Central Schedulers had electronic access to the surgical privileges for Surgeon A, Surgeon B, Surgeon C, Surgeon D, and Surgeon E.

2. Review of the electronic credential files on 2/15/12 at 8:00 AM revealed the following:

a. Surgeon A's credential file lacked a current surgical privileges list.

b. Surgeon B's credential file lacked a current surgical privileges list.

c. Surgeon C's credential file lacked a current surgical privileges list.

d. Surgeon D's credential file lacked a current surgical privileges list.

e. Surgeon E's credential file lacked a current surgical privileges list.

3. Review of the policy "OR-STANDARDS OF CARE," reviewed 2/15/12, revealed the policy lacked the requirement for the Central Schedulers to have access to the surgeon's current surgical privileges.

3. During an interview at 2/15/12 at 8:00 AM, Director of Nursing C acknowledged the electronic surgical privileges for Surgeons A, B, C, D, and E all lacked evidence the electronic surgical privileges contained the surgeons' current surgical privileges.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the anesthesia provider documented the time of the pre-anesthesia evaluation in 5 of 5 closed surgical medical records (Patient #11, 12, 13, 14, and 15), and 2 of 2 open surgical medical records (Patient #16 and 17). Assistant Director of Nursing J stated the surgical services staff performed approximately 10 surgical procedures per month that involved general anesthesia.

Failure to document the pre-anesthesia examination time may indicate the anesthesia provider had not evaluated the patient ' s risk for the procedure immediately prior to the surgical procedure and anesthesia. Failing to assess each patient immediately prior to surgery, could potentially result in anesthesia staff ' s failure to recognize changes in the patient ' s medical condition that could possibly result in the patient experiencing life-threatening complications from the anesthesia.

Findings include:

1. Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF VIRGINIA GAY HOSPITAL, INC.", approved 12/9/10, revealed in part, "The pre-operative assessment will be completed by the anesthesia provider ... prior to the scheduled surgery. This shall be dated, times, and signed."

2. Review of closed surgical patients' medical records on 2/15/12 at 9:00 AM revealed the following:

a. Patient #11 underwent surgery on 2/2/12. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #11.

b. Patient #12 underwent surgery and general anesthesia on 1/25/12. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #12.

c. Patient #13 underwent surgery and general anesthesia on 12/7/11. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #13.

d. Patient #14 underwent surgery and general anesthesia on 11/7/11. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #14.

e. Patient #15 underwent surgery and general anesthesia on 10/19/11. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #15.

3. Review of open surgical patients' medical records on 2/15/12 at 1:35 PM revealed the following:

a. Patient #16 underwent surgery on 2/15/12. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #16.

b. Patient #17 underwent surgery on 2/15/12. Review of the pre-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #17.

4. During an interview on 2/15/12 at 1:30 PM, Assistant Director of Nursing J acknowledged the medical records lacked documentation of the time the anesthesia provider examined the patients. Assistant Director of Nursing J acknowledged the CAH's policy required the anesthesia provider to document the time they examined the patient. Assistant Director of Nursing J also acknowledged if the anesthesia provider failed to document the time they examined the patient, the CAH staff could not determine if the anesthesia provider had examined the patient prior to surgery.

II. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the anesthesia provider documented the time of the post-anesthesia evaluation in 5 of 5 closed surgical medical records (Patient #11, 12, 13, 14, and 15), and 2 of 2 open surgical medical records (Patient #16 and 17). Assistant Director of Nursing J stated the surgical services staff performed approximately 10 surgical procedures per month that involved general anesthesia.

Failure to document the time of the post-anesthesia evaluation could potentially result in the anesthesia provider examining the patient prior to the patient fully recovering from anesthesia, and potentially allowing the CAH nursing staff to discharge a patient with unrecognized complications from anesthesia.

Findings include:

1. Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF VIRGINIA GAY HOSPITAL, INC.", approved 12/9/10, revealed in part, "The post-operative assessment will be completed by the anesthesia provider ... This shall be dated, times, and signed."

2. Review of closed surgical patients' medical records on 2/15/12 at 9:00 AM revealed the following:

a. Patient #11 underwent surgery and general anesthesia on 2/2/12. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #11.

b. Patient #12 underwent surgery and general anesthesia on 1/25/12. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #12.

c. Patient #13 underwent surgery and general anesthesia on 12/7/11. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #13.

d. Patient #14 underwent surgery and general anesthesia on 11/7/11. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #14.

e. Patient #15 underwent surgery and general anesthesia on 10/19/11. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #15.

3. Review of open surgical patients' medical records on 2/15/12 at 1:35 PM revealed the following:

a. Patient #16 underwent surgery on 2/15/12. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #16.

b. Patient #17 underwent surgery on 2/15/12. Review of the post-anesthesia assessment revealed the assessment lacked documentation of the time the anesthesia provider examined Patient #17.

4. During an interview on 2/15/12 at 1:30 PM, Assistant Director of Nursing J acknowledged the surgical patient's medical records lacked documentation of the time the anesthesia provider examined the patient after surgery. Assistant Director of Nursing J acknowledged the CAH's policy required the anesthesia provider to document the time they examined the patient. Assistant Director of Nursing J also acknowledged if the anesthesia provider failed to document the time they examined the patient, the CAH staff could not determine if the patient had recovered from anesthesia prior to the anesthesia provider examining the patient.