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Based on policy review, medical record review, and interview, in one of two records reviewed, the peripherally inserted central catheter (PICC) dressing was not changed every seven days (Patient #1).

Findings include:

Review of the policy "IV Care and Maintenance-Adult," last revised 12/02/22, revealed a PICC line dressing change is needed every seven days and as needed. The hospital PICC team will assess the PICC site and provide dressing care maintenance.

Review on 12/13/24 of the medical record for Patient #1, dated 02/29/24 to 04/04/24, revealed on 03/04/24 at 05:00 PM, a PICC was placed by interventional radiology. On 03/14/24 at 02:15 PM, Staff (JJJ), Registered Nurse changed the PICC dressing for Patient #1 (on the tenth day). On 03/22/24 at 02:23 PM, Staff (KKK), Registered Nurse, changed the PICC dressing for Patient #1 (on the eighth day). On 03/30/24 at 05:30 PM, Staff (LLL), Registered Nurse changed the PICC dressing for Patient #1 (on the eighth day).

Interview on 12/18/24 at 11:04 AM with Staff (SS), Quality Management Project Coordinator verified the PICC line dressing changes for Patient #1 were not performed every seven days per policy on 03/14/24, 03/22/24, and 03/30/24.

Based on policy review, medical record review, and interview, in one out of six records reviewed, a pre-anesthesia evaluation was not completed prior to surgery (Patient #2).

Findings include:

Review of the policy "Sedation for Operative and Invasive Procedures, Diagnostic Testing and Therapeutic Procedures," last revised 07/01/21, revealed monitoring and documentation for minimal, moderate, and deep sedation/anesthesia includes a provider pre-sedation evaluation. The provider pre-sedation evaluation will include a history and physical, a focused physical examination, vital signs, identification of a Mallampati scale (visual evaluation of the throat to predict how difficult it might be to insert a breathing tube. Scoring is one to four with a higher score indicating a potentially more difficult intubation process), and an identification of an American Society of Anesthesiologists (ASA-used to estimate a patient anesthesia risk. One is a health patient, six is a deceased person. A four is a patient with severe systemic disease that is a constant threat to life) status.

Review on 12/11/24 of the medical record for Patient #2, dated 11/26/24, revealed at 09:00 AM, Patient #2 presented to the hospital for an elective laparoscopic (minimally invasive surgical procedure using a camera) insertion of a ventricular peritoneal shunt (a medical device that drains excess cerebrospinal fluid from the brain into the abdomen). At 11:10 AM, the anesthesia record revealed, Patient #2 was intubated without difficulty. At 12:45 PM, the anesthesia record revealed Patient #2 was extubated and breathing on their own. At 01:10 PM, the anesthesia record revealed Patient #2 was transferred to the post anesthesia care unit on a face mask providing oxygen. At 01:52 PM, the anesthesia note by Staff (W), Physician documented a post-anesthesia assessment that Patient #2 was at their mental baseline, needed no respiratory or cardiac support, denied pain and nausea, and had a normal hydration status. At 02:45 PM, Patient #2 was discharged to home. (There was no evidence found that a pre-sedation anesthesia evaluation was completed)

Interview on 12/11/24 at 06:07 PM with Staff (N), Quality Project Manager, verified a pre-sedation anesthesia evaluation was not documented in Patient #2's medical record.

Interview on 12/12/24 at 09:32 AM with Staff (B), Chief Quality and Patient Safety Officer, verified the pre-sedation anesthesia evaluation could not be located.

Based on policy review, medical record review, and interview, in two out of six records, a complete intraoperative anesthesia record was not documented (Patients #1 and #2).

Findings include:

Review of the "Rules and Regulations of the Medical and Dental Staff," dated 02/11/19, revealed the medical record will thoroughly document all operative, other procedures, and the use of anesthesia. Operative reports shall be dictated or written immediately after surgery. Documentation of the attending staff member's supervision of the patient care provided by residents must include as a minimum: the teaching physician was present at the time the service was furnished; the presence of the teaching physician during procedures is documented by the physician or resident in the procedure record or an addendum to the procedure record; and in evaluation and management procedures, the teaching physician must personally document his or her participation in the service in the medical record.

Review on 12/13/24 of the medical record for Patient #1, dated 02/29/24 to 04/04/24, revealed on 02/29/24 at 04:50 PM, the anesthesia record documented Staff (NN), Resident Physician performed an endotracheal intubation on Patient #1 using a glide scope with Staff (U), Anesthesiologist in attendance. Patient #1 had a limited oral opening, but there was good visualization with glide scope. Patient #1's arytenoids (cartilage found in the larynx, which are essential to the production of vocal sound) were fully visible. With the use of the "Dr. Teddy Rutkowski" method with endotracheal tube over fiberoptic, there was some railroading (studding over each cartilage) at the arytenoids, but the tube passed easily through the vocal cords.

Interview on 12/18/24 at 01:00 PM with Staff (U), Anesthesiologist revealed the "Dr. Teddy Rutkowski" method describes a glide scope with fiber optic (video laryngoscope that provides clear view of the vocal cords and laryngeal inlet to help with difficult airway management). The record documented Staff (U) was in the room with Staff (NN), Resident Physician, the entire time. This procedure requires two hands with the glide scope and two hands for the fiber optic device, so Staff (U) and Staff (NN), Resident Physician, intubated Patient #1 together. Staff (U) could not recall what device Staff (U) was holding. Staff (NN) was a senior resident and was not a novice with intubation. The documentation system was flawed.

Interview on 12/18/24 at 03:17 PM with Staff (S), Attending Physician/Kaleida Health System Chief Quality Officer, and Staff (M), Medical Director of Anesthesiology, revealed they reviewed the anesthesia note for Patient #1 on 02/29/24 at 07:16 PM that indicated the ETT size 7.0 tube was secured at 20 centimeters and performed by Staff (NN), Resident Physician with Staff (U) Anesthesiologist in attendance. There is the ability to free text a note. Staff (S) and Staff (M) indicated that the "Dr Teddy Rutkowski" method requires two people to perform the procedure: one to hold the glide scope and another to hold the fiber optic device. From the documentation review, it was unclear on who performed what part of the procedure.

Interview on 12/18/24 at 04:09 PM with Staff (NN), Resident Physician revealed they were there for the intubation of Patient #1 with the glide scope, using the "Dr. Teddy Rutkowski" method. This process requires two people to perform, one using the glide scope and the other using the fiberoptic device. Staff (NN) believed they held the glide scope and Staff (U), Anesthesiologist used the fiberoptic device. During the procedure for Patient #1, Staff (NN) and Staff (U), Anesthesiologist, took turns doing the documentation. The "performed by" and "in attendance" sections must be picked from a drop-down box and cannot be free text. Staff (NN) stated that based on the documentation for Patient #1, "you can't tell who performed the intubation." There is no policy for intraoperative anesthesia record documentation.

Review on 12/11/24 of the medical record for Patient #2, dated 11/26/24, revealed at 11:10 AM, the anesthesia record documented Patient #2 was intubated. At 12:45 PM, the anesthesia record documented Patient #2 was extubated and breathing on their own. (There was no documentation of which provider intubated or extubated Patient #2).

Interview on 12/11/24 at 06:07 PM with Staff (N), Quality Project Manager, verified these findings.