HospitalInspections.org

Based on medical record review of surgical records and staff interview, and policy review; the CAH (Critical Access Hospital) failed to ensure that three of three surgeons failed to sign date with the time that the Pre-Operative Evaluation by Physician occurred just prior to surgery to evaluate the risk of anesthesia and the procedure to be performed. The time was not included in the six records reviewed for patients (12, 26, 27,28, 29, and 30) This failed practice had the potential to affect all surgical patients of the hospital.

Findings are:

A. Review of Resident 12's medical record revealed that the resident was admitted on 6/5/17 at 6:19 AM for a right knee replacement. The Pre-Operative Evaluation was signed and dated 6/5/17 by Doctor A. There was no time on the Evaluation. The time signified that the patient was examined prior to surgery and vital signs and laboratory was reviewed and the patient's condition was satisfactory for anesthesia and surgery.

B. Review of Resident 26's medical record revealed that the resident was admitted on 8/18/17 at 5:46 AM for an endoscopic procedure (tube passed down the mouth into the esophagus, stomach and top of the small intestine) The Pre-Operative Evaluation was signed and dated 8.18.17 by Doctor B. There was no time on the Evaluation.

C. Review of Resident 27's medical record revealed the patient was admitted on 9/26/17 at 6:37 AM for an umbilical hernia repair. The Pre-Operative Evaluation was signed and dated by Doctor B. The time was not included on the Evaluation.

D. Review of Resident 28's medical record revealed that the resident was admitted on 8/2/17 at 9:15 AM for AM for cataract removal on the left eye. Doctor C used a different Pre-Operative Evaluation than Doctors A and B. Doctor C signed that the patient was examined prior to surgery and vital signs and laboratory was reviewed and the patient's condition was satisfactory for anesthesia and surgery. Doctor C failed to put the time of the evaluation on the form.

E. Review of Resident 29's medical record revealed that the resident was admitted on 7/28/17 at 6:17 AM for a laparoscopic cholecystectomy (removal of gall bladder through microsurgery). The Pre-Operative Evaluation was signed and dated 7/28/17 by Doctor B. There was no time on the Evaluation.

F. Review of Resident 30's medical record revealed that the resident was admitted on 6/27/17 at 9:55 AM for repair of a clavicular fracture (collar bone). The Pre-Operative Evaluation was signed and dated 6/27 (no year) by Doctor A. There was no time on the Evaluation.

G. Interview with Clinical Information (CI) G on 10/17/17 at 11 AM revealed that The Pre-Operative Evaluation should include a time as well as a signature and date to ensure it was done prior to the procedure.

H. Review of the facilities History and Physical Policy and Procedure dated as effective 5/2015 stated that if the history and physical was dictated prior to the date of the procedure, it must be updated the day of the procedure. "This will be noted by the surgeon on the history and physical." The attached procedure included the Pre-operative Evaluation by Physician. The time was not included on this form.