HospitalInspections.org

Based on medical staff by-laws, rules and regulations review, medical record review and staff and physician interview the hospital failed to ensure a post-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery for 6 of 6 sampled surgical patients (#9, 10, 6, 2, 8, and 4).

The findings include:

Review of the hospital's Medical Staff By-Laws, Rules and Regulations, revised April 2009, revealed "...2.4.5. Post Anesthesia/Post Anesthetic Note...The anesthesiologist and or anesthetist is responsible for writing a post-anesthetic note after the patient has completed post-anesthesia recovery care, to include at least a description of the presence or absence of anesthesia-related complications..."

1. Open medical record review on 02/10/2011 of Patient #9 revealed a 78 year-old admitted 02/07/2011 for a right total knee replacement. Record review revealed the patient received general anesthesia beginning 02/07/2011 at 0720, ending at 0902. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/10/2011 at 1010 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #9.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."

2. Open medical record review on 02/10/2011 of Patient #10 revealed a 68 year-old admitted 02/07/2011 for a right total knee replacement. Record review revealed the patient received general anesthesia beginning 02/07/2011 at 0733, ending at 1141. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/10/2011 at 1010 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #10.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."

3. Open medical record review on 02/10/2011 of Patient #6 revealed a 64 year-old admitted 02/05/2011 with a right hip fracture and had a right hip hemiarthroplasty (hip replacement) on 02/06/2011. Record review revealed the patient received general anesthesia beginning 02/06/2011 at 0905, ending at 1222. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/11/2011 at 1050 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #6.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."

4. Closed medical record review on 02/10/2011 of Patient #2 revealed a 73 year-old admitted 11/15/2010 with a left hip fracture and a left shoulder fracture. Record review revealed the patient had an internal fixation of the left hip and left shoulder surgery on 11/17/2010. Record review revealed the patient received general anesthesia beginning 11/17/2010 at 1051, ending at 1520. Further record review revealed Patient #2 had a surgical revision of the left hip on 11/18/2010, with general anesthesia beginning at 1820, ending at 2032. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/11/2011 at 1050 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #2.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."

5. Closed medical record review on 02/10/2011 of Patient #8 revealed a 55 year-old admitted 11/02/2010 with repair of wound dehiscence (separation/opening) from previous surgery on 10/25/2010. Record review revealed the patient received general anesthesia beginning 11/07/2010 at 1240, ending at 1327. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/11/2011 at 1050 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #8.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."

6. Closed medical record review on 02/10/2011 of Patient #4 revealed a 55 year-old admitted 10/25/2010 for a hernia repair. Record review revealed the patient received general anesthesia beginning 10/25/2010 at 1345, ending at 1730. Record review revealed no documented evidence of a post-anesthesia evaluation.

Interview on 02/11/2011 at 1050 with administrative staff revealed a post-anesthesia evaluation is to be documented by anesthesia staff. Interview confirmed there was no documented evidence of a post-anesthesia evaluation for Patient #4.

Interview on 02/10/2011 at 1040 with an anesthesiologist revealed "I'm not sure when we do post-anesthesia evaluations. We're in and out of PACU (post-anesthesia care unit) the whole time the patient is in there." Interview further revealed "We need a form to complete. We want to do it right." Interview further revealed the anesthesiologist was not aware of the printed post anesthesia-evaluation form on the back of the hospital's anesthesia record. Interview revealed, "We'll fix it today."