HospitalInspections.org

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure that a physician examined the patient immediately before surgery to evaluate the risk of the planned procedure for 4 of 6 outpatient surgical medical records (Patients 23, 26, 27 and 28) reviewed. This failed practice had the potential to affect all outpatient surgical patients of the CAH. The CAH performed 224 outpatient surgical procedures in the fiscal year of 2015 (7/1/14-6/30/15).

Findings are:

A. Review of Patient 23's medical record on 7/22/15 at 10:10 AM revealed the patient had a diagnostic laparoscopy (a procedure that allows a doctor to look directly at the contents of a patient's abdomen or pelvis), hysteroscopy (a procedure that allows a doctor to look at the lining of a uterus) with a D&C (Dilation and curettage is a procedure to remove tissue from inside a uterus) on 7/17/15. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
-Review of Patient 26's medical record on 7/22/15 at 11:15 AM revealed the patient had epigastric hernia repair (surgical repair of a weakness of the abdominal wall) on 5/5/15. Review of Physician Progress Notes revealed a pre-printed statement that read: "The patient was examined and H&P (history and physical) reviewed prior to surgery to evaluate the risk of the procedure. Patient's condition is satisfactory for surgery." Review of the physician signed and dated entry revealed that the entry lacked evidence of an examination time ensuring it was completed immediately before surgery (11:11 AM).
-Review of Patient 27's medical record on 7/22/15 at 11:40 AM revealed the patient had an esophagogastroduodenoscopy (EGD) (a diagnostic procedure that allows the physician to diagnose and treat problems in the upper gastrointestinal (UGI) tract) and a colonoscopy (an exam used to detect changes or abnormalities in the large intestine and rectum) on 5/19/15. Review of Physician Progress Notes revealed a pre-printed statement that read: "The patient was examined and H&P reviewed prior to surgery to evaluate the risk of the procedure. Patient's condition is satisfactory for surgery." Review of the physician signed and dated entry revealed that the entry lacked evidence of an examination time ensuring it was completed immediately before surgery (11:22 AM).
-Review of Patient 28's medical record on 7/22/15 at 12:00 noon revealed the patient had a mid-urethral sling (surgical treatment of urinary incontinence with placement of a sling) on 2/6/15. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Interview with the Director of Nursing (DON) on 7/22/15 at 12:20 PM confirmed the lack of documented patient examinations immediately before surgery on two of the above patient medical records. The DON also confirmed the physician's signed and dated entries lacked evidence of an examination time ensuring the physician examined the patient immediately before surgery.