HospitalInspections.org

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Based on medical record review, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to ensure an anesthesia qualified practitioner evaluated each patient after surgery for proper anesthesia recovery before discharge for 2 of 5 outpatient surgical records (Patients 18 & 20) reviewed. This failed practice had the potential to affect all surgery patients of the CAH. Total outpatient procedures/surgeries performed from 8/1/18-3/27/19 was 162.

Findings are:

A. Review of Patient 18's medical record (3/27/19 at 11:20 AM) revealed the patient had a Laparoscopic cholecystectomy (removal of the gallbladder through surgical cuts in the abdomen) on 1/10/19. Review of the entire medical record revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

-Review of Patient 20's medical record (3/27/19 at 11:50 AM) revealed the patient had a Colonoscopy (exam used to detect changes in the large intestine and rectum) on 3/5/19. Review of the entire medical record revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

B. Review of the policy and procedure titled Anesthesia Patient Charting (Revised 4/28/14) revealed "Must have a post-operative visit recorded with condition on chart."

C. Interview with the OR (Operating Room) Director (3/28/19 at 1:55 PM) confirmed the above medical records lacked the post-anesthesia evaluations for proper anesthesia recovery before patient discharge.