HospitalInspections.org

Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure an anesthesia qualified practitioner properly evaluated each patient after surgery for proper anesthesia recovery before hospital discharge for 6 of 6 outpatient surgical patients (Patients 26, 26, 28, 29, 30 and 31) reviewed. This failed practice had the potential to affect all surgical patients receiving anesthesia at the CAH. The average monthly number of surgeries with anesthesia is 49.

Findings are:

A. Review of Patient 26's medical record revealed the patient had laparoscopic (operation performed in the abdomen using small incisions with the aid of a camera) cholecystecomy with intraopic cholangiogram (removal of the gallbladder and gallstones) under general (a temporary loss of feeling and a complete loss of awareness that keeps the patient from feeling pain) anesthesia on 3/19/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Respiratory Status;
Cardiovascular Status;
Post-op Hydration; or
Airway.

-Review of Patient 27's medical record revealed the patient had a bilateral ear exam under anesthesia with cerumen (earwax) removal and an adenoidectomy (removal of the adenoids, tissue masses in the upper airway that sit behind the nose) under general anesthesia on 3/25/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Mental Status;
Respiratory Status;
Cardiovascular Status;
Post-op Hydration;
PONV (postoperative nausea and vomiting); or
Airway.

-Review of Patient 28's medical record revealed the patient had a repair of R (right) distal (further away) fibular (outer of the two bones of the lower leg) fracture under general anesthesia on 4/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Mental Status;
Respiratory Status;
Cardiovascular Status;
Post-op Hydration;
PONV; or
Airway.

-Review of Patient 29's medical record revealed the patient had a colonoscopy (a medical procedure that examines the inside of the colon and rectum using a long, flexible tube with a small camera attached) under MAC (Monitored Anesthesia Care, makes the patient feel relaxed and it reduces painful sensations and the awareness of pain) on 8/27/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Respiratory Status;
Cardiovascular Status;
Post-op Hydration; or
Airway.

-Review of Patient 30's medical record revealed the patient had a T-11 (the eleventh thoracic vertebra in the body) kyphoplasty (procedure used to reduce pain in patients that have spinal fractures) under MAC on 6/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Date;
Time;
Mental Status;
Respiratory Status;
Cardiovascular Status;
Post-op Hydration;
PONV;
Airway;
Complications;
Vital Signs; or
CRNA (Certified Registered Nurse Anesthetist) Signature.

-Review of Patient 31's medical record revealed the patient had a hysterscopy (exam of the inside of the cervix and uterus) with dilation (cervix made larger) and curettage (removal of tissue from the inner lining of the uterus) under MAC on 9/10/24. Review of the post anesthesia note revealed the anesthesia provider did not properly document the patient's status before discharge for the following areas:
Mental Status;
Respiratory Status;
Cardiovascular Status; or
Post-op Hydration.

B. Review of the policy and procedure titled Delivery of Anesthesia Care (Last Approved Date 11/2023) stated "A post-anesthesia evaluation is to be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia. This evaluation will be completed by an Anesthesiologist or CRNA. The post-anesthesia evaluation should be documented in the "Anesthesia Pre-Op/Post-Op Documentation" form or in the progress notes and includes:
D. Patient's condition:
1. Level of consciousness, Awake and or Arousable
2. CV [cardiovascular] stability/adequate hydration
3. Pulmonary function stable
4. Airway patent and stable
5. Temperature > 96.8
6. Pain score < 4
7. Nausea/Vomiting
8. Review vital signs
E. Note of any post-anesthetic complications
F. Other pertinent data
G. Need for follow-up/instructions".

C. Interview with the Outpatient Services Manager (9/19/24 at 1:25 PM) confirmed the above outpatient surgery medical records had "inappropriate documentation of the post anesthesia evaluations."