HospitalInspections.org

Based on staff interviews, clinical record review, and facility document review, it was determined the facility staff failed to ensure a presurgical history and physical had an update in one (1) of six (6) surgical records reviewed. (Patient #3).

The findings were:

Patient #3's clinical record was reviewed on 8/26/15. The record contained a "draft" history and physical (H&P) which had been dictated by the surgeon on 01/14/2015 at 10:38 (a.m.) and transcribed on 01/14/15 at 11:28 (a.m.). Patient #3's surgery was scheduled for the following day, 01/15/15. The patient's clinical record also contained a "signed" version of that same H&P that showed the surgeon had authenticated and electrically signed it on 01/20/15. Documentation of the "Preop Assessments" showed the registered nurse (R.N.) marked "Y" (yes) to the question, "H and P completed within last 30 days and available" and also marked "Y" (yes) to the question "H and P updated completed and available." However, the clinical record failed to contain evidence of an update to that H&P. There was a form titled, "History and Physical Interval Note" which read in part, "Standard: History and Physical must be Updated prior to surgery for patients having surgery the day they are admitted, even if H&P was completed the day before. A hard copy of the update must be on the medical record prior to surgery. H&P's (sic) greater than 30 days old must be repeated." This form provided an area for the physician to note there were "No Changes/Additions" to the H&P or for the physician to note there had been changes and to describe those changes. In Patient #3's clinical record, this form was blank.

The facility's Director of Surgical Services was interviewed by the survey team on 8/27/15 at 10:45 a.m. He/she stated that it's the circulator in the operating room (OR) who is supposed to check for the H&P and the update and that the H&P update form was supposed to be completed. When the Director was shown Patient #3's blank History & Physical Interval Note (H&P update form), he/she stated the form was printed out for every patient however it was not always completed, or filled in, since it was not required for all cases.

The R.N. circulator who documented the presence of the H&P and update in Patient #3's clinical record was unable to be interviewed. The R.N. no longer worked at the facility at the time of the survey.

The facility's Chief Medical Officer (CMO) was interviewed by the survey team regarding Patient #3's H&P update on 09/01/15 at 3:00 p.m. The CMO initially stated he/she felt the H&P did not need an update since the patient's surgery was within 24 hours of the H&P dictation. When the regulation requiring an update to the H&P was explained, the CMO stated he/she understood the rationale behind the H&P update requirement and agreed completely.

The Director of Surgical Services was interviewed a second time regarding the H&P update on 09/01/15 at 3:40 p.m. He/She stated an update to the H&P would be expected and acknowledged the only H&P update form found in Patient #3's record was blank.

The facility's policies and procedures related to H&P's were reviewed on 09/01/15. One policy title, "General Surgical Care, 661-052" with a last revision date of 12/2013 read in part, "D. OPERATING ROOM POLICIES... 3. A history and physical may be dictated or completed within 30 days before admission. Significant changes in the health history and physical examination and necessity for the procedure/care must be updated on the day the procedure is performed. Any changes in the patient's condition prior to surgery will be documented in the progress notes, or on the History and Physical. If there are no significant changes in health history, this may be documented as "No Change." It shall be the responsibility of the operating surgeon to see that such physical examinations have been completed." A second policy titled, "Pre-Operative/Pre-Procedure Preparation" with a last revision date of 11/2013 read in part, "POLICY:... 7. History and Physical which has been updated within 24 hours (one day) of procedure. If a History & Physical has been done within thirty (30) days, an interval note may be made on the "History and Physical Update form (sic) or progress note by the attending practitioner to update any changes that may have occurred."