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Based on policy review, medical record review, and interview, the facility failed to follow their policy regarding preoperative anesthesia evaluation prior to out-patient surgery for one of four patients whose records were reviewed (#N3).

Findings included:

1. Review of the facility policy "Preoperative Anesthesia Care", effective October 2011, indicated, "II. Scope- The scope of this policy is within IU Arnett Surgical Services and any inpatient and outpatient units where anesthesia is performed. ...IV. Procedure- ...D. The attending anesthesiologist will perform a preoperative evaluation within 48 hours prior to surgery of each patient. Except in extreme cases the evaluation shall be completed prior to the patient being transferred to the operating suite." The policy listed ten items that should be evaluated including; review of the medical record, interview with the patient to determine history and any anesthesia experiences, evaluation of the patient's respiratory, cardiovascular and neurological status and vital signs, physical exam that includes evaluation of airway, pulmonary and cardiovascular exams, obtaining and/or reviewing any tests or consultations, and a notation made of any anesthesia risk and any potential anesthesia problems identified as well as the patient's condition prior to induction of anesthesia.

2. Patient #N3 presented to the outpatient facility on 07/17/12 and had a laparoscopic cholecystectomy, laparoscopic lysis of adhesions, and intraoperative cholangiography performed by MD3 with general anesthetic provided by MD4. The record contained the three page EMR (Electronic Medical Record) anesthesia record, completed by the anesthesiologist, indicating the "PreOp Reassessment and Pre Induction Re-Evaluation: Complete" was performed at 0839 on 07/17/12. The record lacked a copy of the hand-written pre-anesthesia evaluation or the EMR "Preoperative Evaluation- Anesthesia" form. There was no documentation to indicate the anesthesiologist evaluated all of the ten items listed in their policy that needed to be reviewed prior to anesthesia administration., specifically; evaluation of the patient's respiratory, cardiovascular and neurological status and vital signs, physical exam that included evaluation of airway, pulmonary and cardiovascular exams, obtaining and/or reviewing any tests or consultations, and a notation made of any anesthesia risk and any potential anesthesia problems identified as well as the patient's condition prior to induction of anesthesia.

3. At 12:15 PM on 03/06/13, staff member #A2 reviewed the documentation and confirmed the lack of the "Preoperative Evaluation- Anesthesia" form or the hand written pre-anesthesia evaluation that was usually used by the anesthesiologist, then scanned into the electronic medical record, for patient #N3. However, he/she indicated the documentation "PreOp Reassessment and Pre Induction Re-Evaluation: Complete" from 0839 on 07/17/12 on the three page anesthesia record was how the EMR captured that the evaluation was done.