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Based on interview and documentation review it was determined the Hospital failed to ensure the data collected for the monitoring of the effectiveness and quality of care provided as relates to anesthesia administration.

Findings included:

1) Data and analysis documentation collected for November 2010-February 2011 was reviewed. The only data reviewed and analyzed was related to the provider of anesthesia and the number of cases. There was no documentation in Department of Anesthesia Quality Improvement Meeting Minutes that demonstrated adequate comprehensive analysis is performed to ensure that appropriate quality anesthesia services is reviewed.

2) The Chief of Anesthesia was interviewed in person on 3/28/11 at 12:00. PM. The Chief said that monthly department meetings are held to review cases.

Review of Department Meetings from November 3, 2010 to February 9, 2011 indicated that the meeting minutes did not consistently indicate that quality assessment was performed on cases where anesthesia was provided in the Hospital to evaluate the appropriateness of anesthesia care and service.

Based on interview and documentation review, it was determined that Labor and delivery nursing staff failed to consistently assess a woman's labor pain according to Hospital Policy and procedure in 7 (#1, #2, #5, #6, #7, #8, #9) of 10 records reviewed.

Findings include:

1) Review of the Labor Delivery (LD)-Flow sheet of Patient #1 with the Nurse Manager indicated that on 3/9/11 at 5:22 AM Patient #1 requested pain medication. However, there was no assessment or documentation to indicate the intensity of the labor pain, medication administered, or the response to the pain medication.

Review of policies and procedures related to the obstetrical patient indicated a labor pain and coping assessment shall be performed initially on admission using the Labor Pain Coping Scale (LPCS) and subsequent assessments to be documented every hour as patient condition warrants; and document interventions and response to interventions.

The Nurse Manager of the Maternity Center was interviewed in person on 3/28/11 at 8:40 AM. The Nurse Manager said the Maternity Nursing staff were expected to assess the labor patient's pain, response to medications and document the assessment in the medical record.

2) Patient #2 had her labor pain assessed using the Labor Pain Coping Scale on 3/16/11 at 6:22 AM. Review of Patient #2's record indicated no further LPCS assessments were documented.

3) Patient #5 had no LPCS documented on 3/7/11. Nursing documentation at 11:41 Am indicated anesthesia was called for epidural placement.

4) Patient #6 had no LPCS documented on 3/4/11. Nursing documentation at 1:55 AM indicated an epidural catheter was placed.

5) Patient #7 had no LPCS documented on 2/28/11. Nursing documentation at 2:10 PM indicated an epidural catheter was placed.

6) Patient #8 had no LPCS documented on 2/28/11. Nursing documentation at 7:00 PM indicated an epidural catheter was placed.

7) Patient #9 had no LPCS documented on 2/22/11. Nursing documentation at 8:52 AM indicated an epidural catheter was placed.

Based on medical record review, interviews, and review of policies and procedures, the facility failed to ensure a post anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, for nine (#1, #3, #4, #5, #6, #7, #8, #9, #10) of 10 patients' records reviewed.

Findings include:

1) Review of 10 patient records indicated all but Patient #2 had epidural anesthesia for a C-section. Patient #2 had spinal anesthesia.

2) Review of patient records #1, #4, #9 and #10 indicated no post anesthesia was performed and the forms were blank.

3) Review of patient records #3, #5, #6 and #8 indicated a post-operative assessment was performed, however, only a checked box with an x was marked to indicate no post-operative complications.

4) The anesthesia department staff member signatures on #3 and #6 were illegible.

5) Review of a copy of the Department of Anesthesia's policy for post-anesthesia evaluation, indicated the standards were based on policies and procedures that were lasted amended on October 24, 2004. The Guidelines for Regional Anesthesia in Obstetrics was last reviewed and amended on October 18, 2000.

6) The policies and procedures indicated that post-operative visits will be performed on all in-house patients receiving anesthesia. The post operative written note is to be placed on the back of the pre-operative evaluation. However, the policies and procedure did not include the elements of an adequate post-anesthesia evaluation such as an assessment of: respiratory function, including respiratory rate, airway patency and oxygen saturation; cardiovascular function, including pulse rate and blood pressure; mental status; temperature; pain; nausea and vomiting; and postoperative hydration as recommended by the American Society of Anesthesiologists for routine post-anesthesia assessment.