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Based on interview and record review, the facility failed to 1) failed to follow their grievance process for 1 (P-1) of 11 patients reviewed and failed to 2) allow 1 (P-2) of 11 patients reviewed to be involved with care planning and treatment resulting in loss of patient rights. Findings include:

See Specific Tags:

A-122 Failure to resolve a grievance in a timely manner
A-123 Failure to send notice of grievance decision
A-130 Failure to allow patient involvement in care planning and treatment

Based on interview and record review, the facility failed to maintain a complete and accurate record for 1 (P-2) of 1 patients resulting in a lack of communication amongst staff as well as physical and mental anguish for the patient. Findings include:

See Specific Tags:

A-0438 Maintaining a complete and accurate record

Based on interview and record review, the facility failed to address a grievance for 1 (P-1) of 11 patients reviewed in a timely manner and/or inform them of a lengthy investigation resulting in a loss of patient rights. Findings include:

During an interview with the Clinical Risk Consultant (Staff V) and the Director of Patient Relations, Academic Medical Center (Staff W) on 2/4/2025 at 1330 the complaint filed by P-1's wife on 10/30/2024 was reviewed. Staff V explained the facility ' s Patient Relations Specialist (Staff WW) was on leave and was unavailable to review the work that was done on the complaint. Staff V revealed she had an email chain with information about the investigation that she was referencing. When queried if the facility used an electronic grievance/complaint system, Staff V revealed they do, but the follow-up had not been entered into the system. Staff V revealed The Patient Relations Specialist (Staff WW) spoke with P-1's wife by phone on 10/30/2024 and a Acknowledgement letter was sent on 11/6/2024. On 12/20/2024 the Patient Relations Specialist received the findings of the investigation which found they were unable to substantiate the injury occurred during transfer and P-1's wife was notified by phone of these findings. Staff V revealed a closure letter was drafted on 1/29/2025 but never mailed. When queried if the facility followed the facility policy regarding follow-up and notification to complainants and Staff V stated, "no, we didn't send the 30 day follow-up letters or a closure letter and added "we would have normally sent a letter, but we learned that the patient had died and we were being sensitive to this fact".

Review of the Patient Relations Calls, and Complaints or Grievance Log confirmed the following entries related to P-1 on the following dates:

11/6/2024 - Acknowledgment Letter Sent - "I will need to consult with our hospital leadership team to thoroughly investigate the matter." and "You will continue receiving communication from us every 30 days, until the review is complete unless it is completed sooner."
1/29/2025 - Closure letter drafted (never sent) - "I have consulted with our hospital leadership team, and a thorough review of your medical record was completed." and "On extensive review, including speaking with staff and leadership, we were unable to substantiate this event."
1/30/2025 - (P-1's wife) - needs closure - Awaiting Return call

Review of facility policy titled "Patient Complaints and Grievances, RM-25", policy #9764750 and last revised 9/2021, Documentation Section reveals, "If the concern can be solved within 7 calendar day, the Patient Relations Coordinator will send a Resolution Letter..." and if the concern is unable to be resolved in 7 days a letter of acknowledgement should be sent within 7 days, a follow-up letter every 30 days and a Resolution Letter as soon as possible.

Based on interview and record review, the facility failed to provide 1 (P-1) of 11 patients reviewed with written notice of a grievance investigation closure letter, resulting in denying a patient of their right to a complete grievance process. Findings include:

The complainant was contacted on 2/3/2025 at 0930 to confirm the allegations. The complainant revealed a formal complaint was made with the facility on 10/18/2024 and they have "not been cooperative about getting back to me and I just want to make sure this doesn't happen to other patients."

During an interview with the Clinical Risk Consultant (Staff V) and the Director of Patient Relations, Academic Medical Center (Staff W) on 2/4/2025 at 1330 a complaint filed by P-1's wife on 10/30/2024 was reviewed. Staff V explained the facility's Patient Relations Specialist (Staff WW) was on leave and was unavailable to review the work that was done on the complaint. Staff V revealed she had an email chain with information about the investigation that she was referencing. Staff V revealed a closure letter was drafted on 1/29/2025 but never mailed. When queried if the facility followed the facility policy regarding follow-up and notification to complainants and Staff V stated, "no, we didn't send the 30 day follow-up letters or a closure letter and added "we would have normally sent a letter, but we learned that the patient had died and we were being sensitive to this fact".

Review of facility policy titled "Patient Complaints and Grievances, RM-25", policy #9764750 and last revised 9/2021, Documentation Section reveals, "If the concern can be solved within 7 calendar day, the Patient Relations Coordinator will send a Resolution Letter..." and if the concern is unable to be resolved in 7 days a letter of acknowledgement should be sent within 7 days, a follow-up letter every 30 days and a Resolution Letter as soon as possible.

Based on interview and record review, the facility failed to allow patient participation in the plan of care for 1 (P-2) of 5 patients reviewed for C-section resulting in the loss of patient rights. Findings include:

Review of the medical record for P-2 revealed she was a 27-year-old female G (gravida-number of total pregnancies) 7, Para (P-number of live births) 1, SAB (Spontaneous abortion - miscarriage) 5, who presented to the facility 10/18/2024 at 38 weeks, 1 day for induction of labor due to fetal growth restriction. Upon arrival to the unit, the baby was in cephalic (head) presentation. Induction was started and labor progressed until she was dilated to 8 cm (centimeters). P-2 received an epidural 10/19/2024 at 1712.

An exam done by the resident just prior to rupture of membranes on 10/19/2024 at 1854 revealed a foot was present - a discovery that the baby had flipped and was currently in the breech position (buttock presentation). Education was provided regarding manual manipulation of the baby back into the cephalic presentation versus having a C-section done. P-2 elected to do the C-section.

Review of the OP (operating) Report revealed a start time of 1957. A baby girl, 5 pounds, 6 ounces, was delivered at 2007. The stop time was 2040. The report further detailed the events leading up to the beginning of surgery including consent, preparation, draping, surgical time out, testing of anesthesia and incision as well as detailing the surgery itself.

Review of the C-section documentation and the medication administration record (MAR) for 10/19/2024 revealed the following timeline for events and medications:

1712 Epidural started
1942 Patient in OR
1942 Bupivicaine 0.5% with Epinephrine 1:200,000 injectable 5 ml (milliliters)-epidural
1946 Bupivicaine 0.5% with Epinephrine 1:200,000 injectable 5 ml - epidural
1957 Incision start
2007 Baby delivered
2009 Pitocin 30 units in 500 ml normal saline at 350 ml/hr (milliliters per hour)
2010 Zofran 4 mg (milligrams) IV, Decadron 4 mg IV (intravenous)
2013 Versed 2 mg IV
2019 Versed 2 mg IV
2021 Morphine 2 mg IV
2022 Propofol 20 mg IV
2025 Propofol 20 mg IV
2028 Propofol 20 mg IV
2032 Toradol 30 mg IV
2036 Propofol 20 mg IV
2039 Pitocin reduced to 100 ml/hr IV
2040 Incision closed
2047 To recovery
2052 Epidural stop

Review of P-2 vital sign documentation revealed the following:

10/18/2024 - 1631 Admission: T (Temperature)-98.2, HR (heart rate)-99, R (respirations)-16, BP (blood pressure)-111/69

10/19/2024 - 1635 Labor prior to epidural: T-97.7, HR-77, R-18, BP-118/75

10/19/2024 between 1957 start of C-section at 2021 to administration of Morphine (narcotic pain reliever): HR-91 to 142, BP-140/80 to a high of 125/109

10/19/2024 - 2135 Recovery: HR-77, R-16, BP-108/73

10/20/2024 - 1620 Post-partum: T-98.1, HR-82, R-16, BP-96/59

10/22/2024 - 0745 Closest to discharge: T-98.1, HR-76, R-16, BP-109/60

No documentation was found that an incident report was made neither was there documentation in the medical record that indicated the patient was painful during the C-section. A "Comment" made by Anesthesiologist Staff QQ in the anesthesia medication information on 10/19/2024 at 2013 stated, "Patient is out of control anxious, asking to be put under general anesthesia or give her something ot (sic) relax her after the baby has been delivered. I told her that the medicine i (sic) will give will give her amnesia (loss of memory).."

On 2/4/2025 at 0858, Attending OB/GYN Physician Staff CC stated he was on call on 10/19/2024. P-2's need for a C-section was not emergent. It was his practice to do a "private clamp test" by using a clamp to pinch the area where he would make his incision to check for patient feeling. When pinching, he would look to the anesthesiologist to see if the patient reacted in any way as he was unable to see the patient's face due to the drape. In this case, there was no reaction by P-2, so he started his incision. Staff CC stated he had cut the skin and fascia without incident; however, when he got into the deeper tissue, P-2 was able to feel what he was doing. He explained he "paused, and based on the reaction of the patient, she could feel. I asked anesthesia if we needed to do something differently. He rechecked something and said I was okay to go."

Staff CC further explained when something unusual or emergent happens in the OR (operating room) with vital signs or pain, anesthesia would control the situation. He stated he anticipated the patient would be intubated and put under general anesthesia; however, the patient had expressed it was her wish to hear her baby's first cry and anesthesia was aware of that wish. He also stated anesthesia didn't "like giving general pain meds because it crosses the placenta quickly and can affect the baby." It was explained to the patient we could continue, or she could be given general anesthesia in which case her husband would have to leave the room, and she would be unable to hear that first cry. "The patient initially elected to continue." Staff CC recounted that he and assisting Resident Staff JJ "paused multiple times" as P-2 was screaming and stating she was painful. P-2 was able to move her legs and feet slightly which Staff CC described as being "atypical" and "gave us pause."

With questioning, Staff CC stated in general, a non-emergent C-section can deliver the baby in 3-5 minutes. In this case, it took 2-3 times longer than it normally would have due to the pauses brought on by the patient's reaction during surgery. When queried as to if the patient was experiencing anxiety and the expected pulling/tugging sensations normally felt with C-section versus pain, Staff CC stated he did not know what the patient was experiencing and admitted that at times the pulling/tugging can be interpreted as pain. He further stated in other cases in which the epidural did not seem to be working as well, and the patient seemed to have a high level of sensation to what was happening, that most of the time the case was converted to general anesthesia.

Staff CC further stated he spoke with Anesthesiologist Staff QQ following the C-section who told him the "levels of anesthesia" (epidural) was fine and that the patient was "out of control."

On 2/4/2025 at 1139, First -Year Resident Staff HH corroborated Staff CC's statements and added P-2 was "yelling and screaming in pain asking to be put under but it did not happen. I'm not sure why." On 2/4/2025 at 1148, Fourth year Resident Staff JJ stated the patient "voiced being uncomfortable" and stated surgery was stopped multiple times. She then stated, "She asked to be put under and (OB/GYN Staff CC) said he was okay with general anesthesia. Anesthesia talked to the patient and then told us to continue. The patient was screaming..."

On 2/4/2025 at 1115, Registered Nurse (RN) Staff GG stated she had cared for P-2 on 10/19/2024 day shift. P-2 had told her she had anxiety but had good coping skills. Occasionally, she would need someone to "help her through it." After the epidural was placed, P-2 had reported being able to still feel on the left side. Staff GG assisted the patient to the left side to help the medication distribute to the left. She stated she checked dermatomes (areas of nerves in the skin) and found P-2 was numb at the umbilicus, but it was lower on the left side and could not recall placement. Upon looking in the medical record, she stated she had "forgotten to document" the dermatomes and no documentation was found that the patient could feel on the left side. When queried as to if she had notified anesthesia, she stated she had not because it was shift change, and it was about that time the resident had discovered the baby had turned and they were calling for a C-section. Staff GG assisted with prepping the patient and said she stayed by her head during the C-section. P-2 was anxious, and Staff GG was encouraging her and letting her know pulling and tugging was normal. Staff GG stated P-2 then began screaming and saying she could feel the pain. "She asked them to stop or to be put under." Anesthesia talked with the patient, but Staff GG was unable to hear what was being said. She said surgery resumed, but "nothing had changed. The patient began screaming again." Staff GG admitted this was the first time in 10 years of being a labor and delivery nurse she had seen something like this happen.

On 2/4/2025 at 1434, RN Staff LL stated she was the oncoming night nurse on 10/19/2024. She stated P-2 was "more than a little bit anxious during the incision and said, ' I can feel them. ' That caused P-2 to panic, and she requested help in calming down. I don't know at what point things shifted, but she started being less anxious and was stating she could feel what was happening. The OB stopped and asked (the anesthesiologist) if he needed to give anything. Nothing was given. Anesthesia told the OB to keep going, and he did." Staff LL stated things began to escalate. P-2 was screaming saying, "I can feel everything. Please put me under." Staff LL said P-2 was asked if she was put under if it was okay if her husband left and (P-2) said no. Staff LL further stated it was "very possible (P-2) changed her mind after making that statement." Staff LL further stated in recovery, P-2 did not complain of pain; however, she repeated over and over, "That was awful."

On 2/4/2025 at 1608, Anesthesiologist Staff QQ stated he was on-call and received a page for a C-section. He found the epidural to be working for P-2. She was very anxious, but this was something he cared for on a regular basis. He tried to educate P-2 on sights on sounds without overloading her with information. "She was freaking out a lot." Once they started the C-section and the incision was made, P-2 "started yelling. When the surgeon stopped, she stopped." He said he was debating about starting general anesthesia and recalled P-2 had stated she wanted to hear the baby's first cry and have skin-to-skin contact, so he told her he could not sedate her until the baby was out.

Staff QQ was unable to recall P-2 requesting "to be put out." He stated he was trying to give the patient options and "if she had truly been painful, she would have been painful no matter what." He was queried as to when he would decide to change the plan to which he stated it would "be in conjunction with the OB because medications can affect the baby very quickly... I would get a verbal consent from the patient. It is not an independent decision to make... This is not a common thing that happened."

On 2/5/2025 at 1258, Chief Medical Officer Staff C stated a patient does have the ability to change her mind regarding her care "as long as she has the decisional capacity to do so."

On 2/5/2025 at 1333, Nurse Manager of the Childbirth Center Staff N stated "a patient can change their mind at any time from the initial plan. Increasing or changing medications during surgery would be a discussion with the doctors."

On 2/5/2025 at 1348, Patient Relations Administrative Manager Staff YY stated a "patient can change their mind at any time to share goals of care to the degree the team can accommodate."

Facility policy #15641740 titled "Patient Rights and Responsibilities, RM-27" effective 8/2024 states, "Patients Have: A. The right to participate in the development and implementation of their plan of care 482.13(b)(1) A patient has the right be fully informed, in advance, of proposed care and treatment and to actively participate in the planning and implementation of their care and treatment. B. The patient or their representative (as allowed under State law) has the right to make informed decisions regarding their care, be informed of their health status, and be involved in care planning and treatment and request or refuse treatment..."

Based on interview and record review, the facility failed to ensure staff accurately and completely documented all treatments, interventions and patient response to treatments, interventions and care for 1 (P-2) of 10 patients reviewed according to facility policy and professional standards of practice resulting in lack of communication amongst the interdisciplinary team leading to severe pain and mental anguish for the patient. Findings include:

Review of the medical record for P-2, the patient of concern, revealed she was a 27-year-old female who presented to the facility 10/18/2024 at 38 weeks, 1 day for induction of labor due to fetal growth restriction. Upon arrival to the unit, the baby was in cephalic (head) presentation. Induction was started and labor progressed until she was dilated to 8 cm (centimeters). P-2 received an epidural 10/19/2024 at 1712.

Registered Nurse (RN) Staff GG stated during interview on 2/4/2025 at 1115 that she checked P-2's dermatomes (areas of skin that send signals to the brain through the spinal nerves) and P-2 was still able to feel on her left side after receiving the epidural. She turned P-2 to her left side to "have the medication flow that direction." Staff GG was unable to recall the levels on either side of the patient where the dermatomes could be felt but stated the dermatomes were documented in the medical record. Staff GG was encouraged to find her documentation; however, on getting to the area of the nursing flow sheet where the documentation should be, none was found. Staff GG stated, "I must have forgotten to do it on this patient." Staff GG was queried as to if she reported her findings to an anesthesia provider to which she stated she had not discussed it with him as it was change of shift and she was giving report to the oncoming nurse.

Further review of the medical record revealed an exam was done by the resident just prior to rupture of membranes which revealed a foot-a discovery that the baby had flipped and was currently in the breech position (buttock presentation). Education was provided by the resident regarding manual manipulation of the baby back into the cephalic presentation versus having a C-section done. P-2 elected to do the C-section.

On 2/4/2025 at 0858, OB/GYN Physician Staff CC stated he P-2's need for a C-section was not emergent. It was his practice to check for patient feeling. P-2 did not react to a pinch test with a surgical clamp. Staff CC stated he had cut the skin and fascia without incident; however, when he got into the deeper tissue, P-2 was able to feel what he was doing. He explained he "paused. Based on the reaction of the patient, she could feel. I asked anesthesia if we needed to do something differently. He rechecked something and said I was okay to go." Staff CC explained when issues arose in the OR (operating room) regarding vital signs or pain, anesthesia would be in control. He stated he anticipated the patient would be intubated and put under general anesthesia; however, the patient had expressed it was her wish to hear her baby ' s first cry and anesthesia was aware of that wish... It was explained to the patient we could continue, or she could be given general anesthesia in which case her husband would have to leave the room, and she would be unable to hear that first cry. "The patient initially elected to continue." Staff CC recounted that he and assisting Resident Staff JJ "paused multiple times" as P-2 was screaming and stating she was painful. P-2 was able to move her legs and feet slightly which Staff CC described as being "atypical" and "gave us pause." With questioning, Staff CC stated in other cases in which the epidural did not seem to be working as well, and the patient seemed to have a high level of sensation to what was happening, that most of the time the case was converted to general anesthesia. Staff CC further stated he spoke with Anesthesiologist Staff QQ following the C-section who told him the "levels of anesthesia" (epidural) was fine, and that the patient was "out of control."

No documentation was found in the operative report or other physician documentation of P-2 regarding her wish to hear baby's first cry, being able to feel what was being done, screaming with pain, being able to move her legs and/or feet, or having a discussion following surgery with Anesthesiologist Staff QQ.

On 2/4/2025 at 1139, First-year Resident Staff HH corroborated Staff CC's statements and added P-2 was "yelling and screaming in pain asking to be put under but it did not happen. I'm not sure why." No documentation was found in the medical record of these findings.

On 2/4/2025 at 1148, Fourth-year Resident Staff JJ stated the patient "voiced being uncomfortable" and stated surgery was stopped multiple times. She then stated, "She asked to be put under and (OB/GYN Staff CC) said he was okay with general anesthesia. Anesthesia talked to the patient and then told us to continue. The patient was screaming..." No documentation was found in the medical record of these findings.

RN Staff LL was the oncoming night nurse on 10/19/2024 and was the circulator that was documenting events during the C-section. During an interview on 2/4/2025 at 1434, she stated she received report from RN Staff GG. "It was a little chaotic because they had just called for a C-section for P-2. She stated P-2 did not look uncomfortable, just anxious and she did not recall reporting to anesthesia that the patient had differing dermatomes on the right and left sides. While anesthesia and the OB/GYN surgeon were testing for numbness, P-2 stated she was anxious and would need to be reassured and calmed down. Staff LL stated P-2 was "more than a little bit anxious during the incision and said, 'I can feel them.' That caused P-2 to panic, and she requested help in calming down. I don't know at what point things shifted, but she started being less anxious and was stating she could feel what was happening. The OB stopped and asked (the anesthesiologist) if he needed to give anything. Nothing was given. Anesthesia told the OB to keep going, and he did." Staff LL stated things began to escalate. P-2 was screaming saying, "I can feel everything. Please put me under." Staff LL said P-2 was asked if she was put under if it was okay if her husband left and (P-2) said no. Staff LL further stated it was "very possible (P-2) changed her mind after making that statement."

Staff LL recounted she had seen many patients who were anxious, and some that panicked, but P-2 was screaming, and she felt that was unusual. Staff LL further stated in recovery, P-2 did not complain of pain; however, she repeated over and over, "That was awful."

No documentation was found in the medical record regarding P-2 seeking reassurance for her anxiety, screaming with pain, asking to be put under general anesthesia, or of her statements made in recovery.

The interviews by RN Staff GG and RN Staff LL regarding events in the OR were corroborated by Charge Nurse Staff NN, Nursery RN Staff PP, and OB Technician Staff OO on 2/4/2025. No documentation was found in the medical record by any of these staff members regarding P-2 being painful, screaming, and requesting to be "put under" during the C-section.

On 2/4/2024 at 1608, Anesthesiologist Staff QQ stated he found the epidural to be working for P-2. She was very anxious, but this was something he cares for on a regular basis. "She was freaking out a lot." Once they started the C-section and the incision was made, P-2 "started yelling. When the surgeon stopped, she stopped." He said he was debating about starting general anesthesia and recalled P-2 had stated she wanted to hear the baby's first cry and have skin-to-skin contact, so he told her he could not sedate her until the baby was out.

Staff QQ was unable to recall P-2 requesting "to be put out." He was queried as to when he would decide to change the plan to which he stated it would "be in conjunction with OB because medications can affect the baby very quickly... I would get a verbal consent from the patient. It is not an independent decision to make... This is not a common thing that happened."

No documentation was found in the medical record regarding P-2 expressed desire to hear baby's first cry and have skin-to-skin contact or screaming she was painful. A "comment" was made by Anesthesiologist Staff QQ in the anesthesia medication information on 10/19/2024 at 2013. The comment stated, "Patient is out of control anxious, asking to put under general anesthesia or give her something ot (sic) relax her after the baby has been delivered. I told her that the medicine i (sic) will give will give (sic) her amnesia.."

Further review of the medical record revealed an entry dated 10/21/2024 was found in the medical record by Anesthesia Care Nurse Staff EE noting P-2 "reports no complications from epidural anesthesia." During interview, Staff EE on 2/4/2025 at 0950 she stated she was unaware there had been issues during the C-section; however, while they were talking P-2 had stated she had been uncomfortable. When queried about her documentation, Staff EE stated the note was "an assessment of (P-2's) post-epidural state. There was no residual numbness, bruising etc." Staff EE further stated she would not document that the patient had discomfort because it was not something she "could take care of in the moment."

Continued review of the medical record revealed an "Anesthesia Progress Note" dated 10/22/2024 at 1043 which stated, "She is awake...no issues/complications with the epidural for the anesthesia. Recollection of her events during that case were reviewed and discussed in the presence of her husband and (Staff EE)...She is aware and recognizes her pre-existing anxiety disorder which complicates her ability to cope in stressful situations especially in unusual situations like during the c section (sic) when she was completely awake, unable to control anything, and remembers being calm with occasional unpleasant recurrent panic attacks up to the time when incremental doses of midazolam and propofol provided mild sedation. However, she is appreciative of the opportunity to witness the birth of her daughter and the appropriate timing of her sedation."

During an interview with P-2 on 2/3/2025 at 1236 she stated she had obtained a copy of her medical records and found them to be inaccurate-specifically the documentation by Anesthesiologist Staff QQ. She stated the documented "anxiety with coping issues" was inaccurate. She cited the only coping issue she had was with the death of her father 10 years previous. P-2 further stated she was not on any medications for anxiety. She stated she was not calm but was screaming in pain and begging to be "put under." She denied ever having a panic attack and was "definitely not appreciative" of the timing of the anesthesia as none was given until after they were "sewing me up." P-2 further stated both she and her spouse have had to seek counseling because of the traumatic C-section and the events surrounding it.

Facility policy #14704975 titled "Rules and Regulations of the Medical Staff, MS-24" effective 2/2024 states, "Operative and/or Procedural Documentation...Operative Note Shall (sic) include any procedure requiring sedation or anesthesia, including, but not limited to surgical procedures, endoscopy, interventional radiology, invasive cardiology, and cardiac catheterization procedures. Such reports must include a description of the techniques, findings and tissues removed or altered and signed by the operating surgeon. Operative reports are to include the following information and are required to be entered into the record within 24 hours: a. Name and hospital identification number of the patient, b. Date/time of surgery...g. Complications (if any)..."

Facility policy #15591656 titled "Section of Anesthesiology, MS-28" effective 5/2024 states, "Intraoperative/procedural anesthesia (time-based record of events) A. Immediate review prior to initiation of anesthetic procedures...B. Monitoring of the patient...C. Doses of drugs and agents used, times and routes of administration and any adverse reactions.. D. The type and amounts of intravenous fluids used... E. The techniques(s) used and patient position(s). F. Intravenous/intravascular lines and airway devices that are inserted, including technique for insertion and location. G. Unusual events during the administration of anesthesia..."

The American Nurses Association's "Principles for Nursing Documentation Guidance for Registered Nurses" dated 2010 states, "Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory, and legislative, reimbursement, research, and quality activities...Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential...Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care. Assessments; Clinical problems; Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient's designated support person and other third parties...Patient responses and outcomes, including changes in the patient's status..."

Based on interview and record review, the facility failed to ensure a post-anesthesia assessment was performed according to facility policy for 1 (P-2) of 5 patients reviewed who had received surgical intervention, resulting in the potential for unidentified patient needs and poor patient outcomes. Findings include:

Review of the medical record for P-2 revealed she was 27-year-old female who received a C-section on 10/19/2024 at 1957. Review of the "Anesthesia Progress Note", which included vital signs, medications, pain, assessment, and notes of discussion with patient, were dated 10/22/2024 at 1043.

During interview on 2/4/2025 at 1608, Anesthesiologist Staff QQ was queried as to why the post anesthesia evaluation was completed more than 48 hours post procedure, to which he stated the level of anxiety of P-2 was "not a common thing to happen." He chose to "wait a couple of days" to enjoy her newborn baby.

Facility policy #15591656 titled "Section of Anesthesiology, MS-28" effective 5/2024 states, "A postanesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care... Inpatient: Anesthesiologist familiar with the anesthesia management of the patient will visit the patient post-op within 48 hours, review and document the following: Cardiopulmonary status, Level of consciousness, Any follow-up care and/or observations and patient instructions, Any complications occurring during post anesthesia recovery, Patient concerns regarding anesthesia provided, Temperature, Pain, Nausea and vomiting, Postoperative hydration"