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Based on documentation review it was determined the Hospital failed to ensure all medical record entries were complete and contained sufficient information to identify the staff member providing the service provided in one of five medical record reviewed.

Findings included:

Review of 3/24/10 anesthesia record documentation indicated the Patient was given an oral medication, Midazolam (used to cause relaxation or sleep before surgery), at 8:27 AM, prior to being taken into the OR. It was noted establishment of IV access was difficult and help was requested. Four attending anesthesiologist and the Resident tried multiple times to establish the IV access without success. An ultrasound device was also utilized in an unsuccessful attempt to establish IV access in the Patient ' s right Femoral Vein (large vein in the groin area). Documentation did not identify who all of the anesthesioligist were that attempted to start an IV, nor did it identify the number of times each anesthesiologist tried unsuccessfuly to start an IV.