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Based on record review and interview the hospital failed to ensure consents were properly executed by failing to: a) obtain a physician signatures for a blood consent for 1 of 2 patients who had received blood (Patient #2) and b) document the alternative treatment and associated risks or the name of the physician authorized to perform the procedure/treatment for 5 of 10 patients scheduled for a procedure (#2, #3, #14, #15, #16) out of 23 sampled medical records. Findings:

1) no documented evidence of a physician's signature on a consent for blood
Patient #2
Review of the medical record for Patient #2 revealed an eighty-four year old male admitted to the hospital on 03/24/11 for shortness of breath and congestion. Further review revealed a history of non-hodkins type Lymphoma and anemia.

Review of the "Instructions and Consent for Patient Receiving Blood Transfusion" form dated 04/01/11 for Patient #2 revealed no documented evidence the physician had authenticated the consent.

Review of the Informed Consent policy, last revised 04/10 and submitted as the one currently in use, revealed

2) no documented evidence of the alternative treatment and associated risks or the name of the physician authorized to perform the procedure/treatment
Patient #2
Review of the medical record for Patient #2 revealed an eighty-four year old male admitted to the hospital on 03/24/11 for shortness of breath and congestion. Review of the Physicians' Orders dated 03/31/11 at 0830 (8:30am) revealed an order for, "Central Line Placement for tomorrow. Consents for above".

Review of the "Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form dated 03/31/11 and signed by MD S13 revealed no documented evidence reasonable therapeutic alternatives and risks associated therewith and the risks of no treatments had been discussed with Patient #2 or his family. Further review revealed no documented evidence the name of the physician authorized to perform the procedure had been documented as required.

Patient #3
Review of the medical record revealed an eighty-seven year old female admitted to the hospital on 02/23/11 for pneumonia and possible sepsis post surgical procedure. Review of the "Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #3 and signed by MD S13 revealed no documented evidence of the following: reasonable therapeutic alternatives and risks associated therewith; and the risks of no treatments had been discussed with Patient #3 or his family. Further review revealed no documented evidence the name of the physician authorized to perform the procedure had been documented as required.

Patient #14
Review of the medical record for Patient #14 revealed a seventy-five year old male admitted to the hospital on 03/14/11 for an abscess of the right calf. Review of the "Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #14 and signed by MD S13 revealed no documented evidence of the following: the nature and purpose of the operation or medical procedure had been explained in general terms; reasonable therapeutic alternatives and risks associated therewith; and the risks of no treatments had been discussed with Patient #14 or his family. Further review revealed no documented evidence the name of the physician authorized to perform the procedure had been documented as required. Review of the signatures revealed MD S13 signed the consent on 03/16/11 at 0945 (9:45am) and the patient and witness on 03/15/11 at 1700 (5:00pm).

Patient #15
Review of the medical record for Patient #15, revealed a 25 year old male admitted to the hospital with the diagnosis of cholelithiasis and was scheduled for a Laproscopic Cholecystectomy on 03/31/11 under general anesthesia.

Review of the "Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #15 and signed by MD S13 revealed no documented evidence of the following: reasonable therapeutic alternatives and risks associated therewith; and the name of the authorized physician had been discussed with Patient #15 or his family.

Patient #16
Review of the medical record for Patient #16, revealed a thirty-eight year old female admitted to the hospital on 04/01/11 with cholelithiasis. Further review of the medical record revealed she was scheduled for a Laproscopic Cholecystectomy on 04/01/11 under general anesthesia.

Review of the "Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #16 and signed by MD S13 revealed no documented evidence of the following: reasonable therapeutic alternatives and risks associated therewith; and the name of the authorized physician had been discussed with Patient #15 or his family.

In a face to face interview on 04/04/11 at 2:30pm RN S3 Assistant Director of Nursing indicated consents should be reviewed by completeness before the patient is sent for surgery and if it not complete the OR (Operating Room) Department should be notified. Further S3 indicated if the patient does reach the surgery suite and the consent is still not complete, the surgeon should be contacted.

In a face to face interview on 04/06/11 at 11:45am MD S4 Medical Director indicated he was not aware physicians were not completing the informed consents.

Review of the Informed Consent policy, last reviewed 04/10 and submitted as the one currently in use revealed.... "It is the responsibility of the physician performing a procedure in the hospital to explain the procedure to the patient".

Based on record review and interview the Registered Nurse failed to supervise and evaluate the care of patients as evidenced by: 1) failing to ensure the surgical checklist was completed on all patients scheduled for a surgical procedure before sending patients to the operating suite for 4 of 6 patients with scheduled surgical procedures (#2, #13, #14, #15) and 2) failing to clarify incomplete discharge orders resulting in a nurse completing the discharge orders of diet, activity and restrictions from information found in the patient's medical record (#18) out of a total of 23 sampled medical records. Findings:

Patient #2
Review of the medical record for Patient #2 revealed an eighty-four year old male admitted to the hospital on 03/24/11 for shortness of breath and congestion. Further review revealed Patient #2 was scheduled for central line placement on 04/01/11.

Review of the "Surgery Pick Up Slip" no date documented for Patient #2 revealed no documented evidence vital signs had been assessed (blood pressure, pulse respirations or temperature).

Patient #13
Review of the medical record for Patient #13 revealed a seventy-one year old female admitted to the hospital on 03/25/11 for Pneumonia, Sacral Decubitus and sepsis with a history of HTN (Hypertension), DM (Diabetes Mellitus) and Metastatic Breast Cancer. Further review revealed Patient #13 was scheduled for an I&D of a sacral decubitus on 03/27/11 under general anesthesia.

Review of the "Surgery Pick Up Slip" dated 03/27/11 for Patient #13 revealed no documented evidence the following had been completed: allergies, anesthesia consent was signed, Flowtron Excel or Ted Hose applied, pre-op enema, EKG, Vital signs assessed and documented (blood pressure, pulse, respiration, temperature) or pre-op medication administered. Further review of the form revealed no documented signature of the the nurse who had assessed the patient for surgery.

Patient #14
Review of the medical record revealed Patient #14 , a seventy-five year old male, was admitted to the hospital on 03/14/11 dated 03/17/11 revealed a seventy-five year old male with an infected right calf abscess. Further review revealed Patient #14 was scheduled for an I&D (Incision and Drainage) of the right calf on 03/16/11 under general anesthesia.

Review of the "Surgery Pick Up Slip" dated 03/16/11 for Patient #14 revealed no documented evidence the following had been completed: allergies, anesthesia consent was signed, Vital signs assessed and documented (blood pressure, pulse, respiration, temperature). Further review of the form revealed the nurse had signed and dated as complete.

Patient #15
Review of the medical record for Patient #15, revealed a 25 year old male admitted to the hospital with the diagnosis of cholelithiasis and was scheduled for a Laproscopic Cholecystectomy on 03/31/11.

Review of the "Surgery Pick Up Slip" (no date documented for Patient #15 revealed no documented evidence the following had been completed: allergies, lab (UA (Urinalysis) or CBC), pre-op medication administered, or the surgical markings verified. Further review revealed no documented evidence the form had been signed and dated by the nurse.

In a face to face interview on 04/06/11 at 2:30pm RN S2 CNO (Chief Nursing Officer) indicated the checklist for surgery should be completed before the patients leaves the unit and is brought to surgery.

Review of the "Pre-Operative Surgical Checklist" (Surgery Pick-up List) last revised 04/10 and submitted as the one currently in use revealed the list is a tool used to verify that all preparation of the surgical patient is complete. Further review revealed..... " The nurse in charge of patients scheduled for a surgical procedure completed and signs the "Surgical Checklist" prior to the patient being transported to surgery. All items must be completed prior to transporting the patient to OR (Operating Room) verifying all items are correct and complete". Any omission on the "Surgical Checklist" must be researched by the floor nurse. If unable to complete an item, it is noted on the checklist and the Surgical Department is notified".


2) failing to clarify incomplete discharge orders resulting in a nurse completing the discharge orders of diet, activity and restrictions from information found in the patient's medical record
Patient #18
Review of the medical record for Patient #18 a sixty-three year old female admitted to the hospital on 03/31/11 with pneumonia and a history of CHF (Congestive Heart Failure).

Review of the Physician's Discharge Orders for Patient #18 (no date documented) revealed no documented evidence of orders for a diet, level of activity or restrictions.

Review of the Nursing Discharge Instructions given to Patient #18 revealed a low salt diet and activity as tolerated. Further review revealed no documented instructions of any restrictions for Patient #18 after discharge.

In a face to face interview on 04/05/11 at 2:00pm RN S21 indicated the physicians sometimes forget to complete all of the information contained on the form. Further she indicated it was the practice of the nurses to complete the discharge information for the patient with the information using what they were doing at the time of discharge.

In a face to face interview on 04/05/11 at 2:00pm RN S2 Assistant DON (Director of Nursing) indicated the nurse should have clarified the order with the physician. Further she indicated it was not appropriate for the nurse to assume what the patient was doing at the time of discharge was what he/she intended for the patient to continue after discharge.

Based on record review and interview the hospital failed to implement the patient's plan of care by failing to follow the physician's orders for monitoring of a patient's blood pressure every 4 hours for 1 of 23 sampled patients (Patient #22). Findings:

Patient #22: The medical record for Patient #22 was reviewed. Documentation revealed an admit date of 03/31/11 with diagnosis of Acute Cerebral Vascular Accident (CVA). Review of the Patient Medication Orders dated and signed by the physician 04/01/11 revealed an order for Clonidine HCL 0.2 mg by mouth every 4 hours as needed with a SBP (systolic blood pressure) over 180 and DBP (diastolic blood pressure) over 100. Review of the electronic Graphic Record revealed Patient #22's blood pressure was not monitored every 4 hours from 04/01/11 to 04/06/11 for hypertension to determine if the Clonidine was to be administered as ordered.

This finding was confirmed by S15, RN, Rehabilitation Unit, and S16, RN Risk Management on 04/06/11 at 2:30pm.

Based on record review and interview, the hospital failed to ensure that all drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This was noted in the medical records for 1 of 10 patients (Patient #1) whose medical record was reviewed for medication administration out of a total sample of 23 patients. Findings:

Patient #1: Medical record reviewed revealed orders dated 4/02/11 at 7:00 p.m. for 240mg of Surfak to be administered twice daily and 15units of Novalog to be administered before meals. Review of the medical record including the medication administration record revealed no documentation to indicate that Patient #1 received the ordered 240mg of Surfak on the p.m. of 4/02/11 or the ordered 15units of Novalog before breakfast on 4/03/11. Further review revealed orders dated 4/03/11 at 1:50 p.m. for 40mg of Protonix to be administered "Now". Review of the medication administration record revealed the Protonix was administered at 3:41 p.m. on 4/03/11 (1 hour and 51 minutes after being ordered to be administered "Now").

The hospital's policy/procedure titled "Administration of Medications: General" was reviewed. The policy/procedure documents "Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice. The hospital's policy/procedure titled "Medication Management and Administration" was reviewed. The policy/procedure indicates that "Now" orders should be administered within one hour of receiving the order.

S6 (RN) was interviewed on 4/04/11 at 2:00 p.m. S6 reviewed the medical record of Patient #1 and confirmed that the Surfak and Novalog were not administered as ordered. S6 also confirmed that the "Now" order for Protonix was not administered within 1 hour of being ordered as documented in the hospital's policy/procedure.

Based on record review the hospital failed to ensure blood had been administered according to policy and procedure as evidenced by a nurse failing to clarify an order for blood which did not contain the rate of administration for 1 of 2 patients who was administered blood out of a total of 23 sampled medical records (#13). Findings:

Review of the medical record for Patient #13 revealed a seventy-one year old female admitted to the hospital on 03/25/11 with anemia and sacral decubitus. Review of the Physician's Orders dated 03/25/11 at 6:50 (am or pm not documented) revealed an order to, "T&M (Type and Match) 3 u (units) pck (packed) cells to give".

Review of the "Blood Bank Transfusion Record" for Patient #13 revealed the following: Unit #010394 (no volume documented) given 03/25/11 over a time period of 1 hour and 20 minutes - from 2100 (9:00pm) through 2220 (10:20pm); Unit #010966(no volume documented) given over a time period of three hours - 03/25/11 from 2320 (11:20pm) through 0220 (2:20am); and Unit #010394 (same number as Unit #1 documented for #3 and no volume documented) given over a two hour time period - 03/26/11 from 0230 (2:30am) through 0430 (4:30am).

In a face to face interview on 04/06/11 at 11:45am MD S4 Medical Director indicated physicians use the labs protocol for the rate blood is infused. Further S4 verified the protocol was not part of the chart and was not signed by the physician as an order.

Review of the "Blood/Blood Component Transfusion" policy last revised 02/10 and submitted as the one currently in use revealed.... "Administer blood unit at prescribed rate if no adverse effects occur after the first fifteen minutes of the initiation of the transfusion".

Based on record review and interview the hospital failed to ensure all History and Physicals (H&P) were completed within 24 hours of admit for 2 of 23 sampled medical record (#2, #3). Findings:

Patient #2
Review of the medical record for Patient #2 revealed an eighty-four year old male admitted to the hospital on 02/26/11 for shortness of breath and congestion. Further review revealed a history of non-hodkins type Lymphoma and anemia. Review of the H&P for Patient #2 admitted 02/26/11 revealed the information had been dictated on 02/27/2011 by MD S13 and typed on 03/01/11(five days after admit to the hospital).

Patient #3
Review of the medical record for Patient #3 revealed an eighty-seven year old female admitted to the hospital on 02/17/11 for abdominal pain, fever, no appetite, nausea and vomiting. Review of the H&P for Patient #3 admit date 02/17/11 revealed the information had been dictated on 02/19/11 by S17 and typed on 02/20/11 (three days after admit to the hospital).

Review of the Medical Staff By-Laws "Rules and Regulations" last reviewed in January 2011 revealed.....
2.2 Admission History: Each patient admitted for inpatient care shall have complete admission history and physical examination recorded by a qualified physician.....within 24 hours of admission....".

In a face to face interview on 04/06/11 at 11:45am MD S4 Medical Director indicated he was not aware physicians were not completing H&Ps within 24 hours.

Based on record review and interview, the hospital failed to ensure that medication orders were reviewed for appropriateness (therapeutic appropriateness of a patient's medication regimen; therapeutic duplication in the patient's medication regimen; appropriateness of the drug, dose, frequency, route and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and other contraindications) by a pharmacist before the first dose is dispensed. This was noted in the medical records for 1 of 10 patients (Patient #1) whose medical record was reviewed for pharmacist review out of a total sample of 23 patients. Findings:

Patient #1: Medical record reviewed revealed orders dated 4/02/11 at 7:00 p.m. for 240mg of Surfak to be administered twice daily, 100mg of Labetalol to be administered three times daily; and 2.5mg of Minoxidil to be administered twice daily. Review of the medical record including the medication administration record revealed no documentation to indicate that Patient #1 received the ordered 240mg of Surfak on the p.m. of 4/02/11or the ordered 15units of Novalog before breakfast on 4/03/11. Further review revealed that the 100mg of Labetalol was administered at 9:58 p.m. on 4/02/11 and the 2.5mg of Minoxidil was administered at 9:57 p.m. on 4/02/11.

The hospital's policy/procedure titled "Medication Management and Administration" was reviewed. The policy/procedure documents that medication orders will be reviewed for appropriateness (therapeutic appropriateness of a patient's medication regimen; therapeutic duplication in the patient's medication regimen; appropriateness of the drug, dose, frequency, route and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and other contraindications) by a pharmacist before the first dose is dispensed.

S8 (Director of Pharmacy) was interviewed on 4/04/11 at 2:15 p.m. S8 reviewed the medical record of Patient #1. S8 reported the orders written on 4/02/11 at 7:00 p.m. for Patient #1 were not reviewed by a pharmacist until the a.m. on 4/03/11. S8 indicated that the p.m. dose of 240mg of Surfak not administered to Patient #1 on 4/02/11 as ordered. S8 reported the 100mg of Labetalol was administered at 9:58 p.m. on 4/02/11 prior to being reviewed by a pharmacist and the 2.5mg of Minoxidil was administered at 9:57 p.m. on 4/02/11 prior to being reviewed by a pharmacist.

Based on observation and interview, the hospital's food services director failed to ensure the implementation of policies/procedures relating to safe food handling as evidenced by failing to ensure that prepared salads and cakes were labeled with the date and time of preparation so that the shelf life could be determined and by failing to ensure that a system was in place for cleaning and sanitizing containers/bins used to store dry goods such as flour, beans, and peas. Findings:

Observations and interviews in the kitchen on 4/06/11 between 11:15 a.m. and 11:40 a.m. revealed the following:
-Fifteen (15) individual containers of prepared salads and twelve (12) individual containers of individual slices of cake were noted to be in the refrigerator in the kitchen. There was no documentation on the containers of the salads or the cakes to indicate the date and time of preparation so that the shelf life of the food items could be determined. S19 (Registered Dietician) was present at the time of this observation. S19 reported the containers should have been marked with the date of preparation so that the shelf life of the salads and cakes could be determined.
-Large clear storage containers/bins were noted in the dry goods storage area of the kitchen. One container/bin contained bulk flour, one contained beans, and one contained peas. S19 (Registered Dietician) was present at the time of this observation. When asked about the schedule and/or process for cleaning and sanitizing the containers/bins, S19 reported that the containers/bins should be cleaned when empty. When asked if there are times when the containers/bins are refilled with flour, beans, or peas prior to being emptied, S19 indicated that there are times when the containers/bins are refilled with flour, beans, or peas prior to being emptied. S19 was unable to report when the last time the containers/bins had been cleaned and sanitized. The hospital was unable to produce a cleaning/sanitizing schedule for the containers/bins and was unable to determine the date of last cleaning/sanitizing.

Based on record review, observation and interview, the hospital's infection control officer failed to ensure the implementation of effective infection control practices within the hospital. This was evidenced by:

1. Failing to ensure compliance with the hospital's infection control plan by failing to ensure the implementation of process improvement measures once actual and/or potential problems were identified. Findings:

The hospital's infection control plan and infection control data was reviewed. The infection control plan documents "Application of the performance improvement process for problem resolution through: Identification of actual or potential problems within a process using statistical data collection; Plan-identification of corrective measures and desired outcomes; Do-implementation of process improvement via policy development/revision and/or education; Check-evaluation of the effectiveness of the corrective measures by comparing the goals with what was actually achieved; Act-building or incorporating the corrective measure (s) into the process and monitoring activities". The infection control surveillance data revealed problems identified in 2010 relating to physician non-compliance with handwashing/hand hygiene practices. Documentation revealed the overall hand hygiene compliance rate for physicians was at 50% for 3 quarters in 2010 and 60% for 1 quarter in 2010. Documentation revealed a total of nine physician observations for the first quarter of 2011 with a physician compliance rate of 56%. Documentation revealed that physician S22 failed to wash his hands during 3 of 3 observations in 2011. Review of the Infection Control Committee Meeting Minutes for the most recent meeting (dated 3/21/11) revealed no documentation to indicate that measures were implemented relating to the identified breakdown in physician compliance with handwashing/hand hygiene.

The hospital's Infection Control Officer (S10) was interviewed on 4/06/11 at 9:15 a.m. When asked what measures were implemented within the hospital relating to the identified breakdown with physician compliance with hand hygiene, S10 reported that information relating to this breakdown was going to be discussed in the upcoming meeting of the Medical Executive Committee. When asked to provide information relating to measures already implemented as this breakdown in physician compliance with handwashing/hand hygiene was identified in 2010, S10 was unable to provide documented evidence of corrective action relating to physician compliance with handwashing/hand hygiene. In addition, S10 was unable to provide documented evidence to indicate that any interventions were implemented relating to the surveillance results indicating that S22 failed to perform handwashing/hand hygiene prior to patient care for 3 of 3 observations in 2011.

The meeting minutes for the most recent 2 meetings of the Medical Executive Committee (3/16/11 & 2/09/11) were reviewed. This review revealed no documented evidence to indicate that measures were implemented relating to the identified breakdown in physician compliance with handwashing/hand hygiene.

The hospital's Chief of Staff (S4) was interviewed on 4/06/11 at 11:55 p.m. S4 reported that he is planning to discuss the need to comply with handwashing and hand hygiene practices with the medical staff at the upcoming meeting. When asked to provide information relating to measures already implemented as this breakdown in physician compliance with handwashing/hand hygiene was identified in 2010, S4 was unable to provide documented evidence of corrective action relating to physician compliance with handwashing/hand hygiene. In addition, S4 was unable to provide documented evidence to indicate that any interventions were implemented relating to the surveillance results indicating that S22 failed to perform handwashing/hand hygiene prior to patient care for 3 of 3 observations in 2011.


2. Failing to ensure that the cleaning and disinfecting of ED (Emergency Department) rooms included the removal of biohazardous waste, soiled linen and trash from the room between patients. Findings:

Observations and interviews in the ED (Emergency Department) between 9:40 a.m. and 10:00 a.m. on 4/05/11 revealed the following:
-ED room #6 was reported to be ready for a new patient. Observations in this ED room revealed soiled waste in the red biohazardous waste container, soiled waste in the trash can including a piece of gauze that was red in appearance, and soiled linen in the linen hamper. In addition, a strong odor was noted in the trash can. In an interview with S9 (Registered Nurse) at the time of this observation, S9 indicated that the cleaning and disinfecting of ED rooms between patients does not always include the removal of waste and/or linen used in the treatment of patients.

The hospital's Infection Control Officer (S10) was interviewed on 4/06/11 at 9:15 a.m. S10 reported that she was not aware that the cleaning and disinfecting of ED rooms between patients did not include the removal of waste and/or linen used in the treatment of patients. S10 reported that all waste including biohazardous waste, soiled linen, and trash should be removed from the ED room between patients.



3. Failing to ensure that a registered nurse in the ED (Emergency Department) was trained and knowledgeable on the manufacturer's instructions for use on the disinfectants used in the hospital. Findings:

S9 (Registered Nurse) was interviewed on 4/05/11 at 9:10 a.m. When asked about the disinfectants used by ED personnel in the hospital's ED, S9 indicated that "TB Quat" is a disinfectant used in the ED for disinfection. When asked about the process for using "TB Quat" to disinfect a surface area, S9 reported that she sprays the "TB Quat" on the surface area, lets it sit for "one minute" and then wipes it off.

Review of the manufacturer's instructions for disinfection revealed that the "TB Quat" is to remain in contact with the surface area for 5 minutes in order to work as a tuberculocidal agent and for 10 minutes in order to work as a virucidal agent.

Review of S9's personnel record revealed no documentation to indicate that S9 had received education and training on the use of "TB Quat".


4. Failing to ensure the separation of clean supplies and soiled items including biohazardous waste.

Observations and interviews on the medical unit between 11:05 a.m. and 11:15 a.m. on 4/04/11 revealed the following:
-Soiled utility room was noted to have one red container containing biohazardous waste and two hampers containing soiled linen. Interview with the CNO (S2) revealed that this room is used to hold trash, soiled linen and biohazardous waste. Two cases of trash bags were noted to be stored in this room. In an interview with S20 (CNA) at the time of this observation, S20 reported that the trash bags are used to line the trash cans in the patient care areas including patients rooms. When asked if the trash bags that were stored in the soiled utility room would be taken from the soiled utility room to patient care areas, S20 replied yes.

Observations and interviews in the ED (Emergency Department) between 9:40 a.m. and 10:00 a.m. on 4/05/11 revealed the following:
-Soiled utility room was noted to have one red container containing biohazardous waste. Interview with the CNO (S2) revealed that this room is used to hold trash, soiled linen and biohazardous waste. One case of trash bags and two rolls of toilet paper were noted to be stored in this room. In an interview with S2 (CNO), S2 reported that the case of trash bags and the rolls of toilet paper should not be stored in a soiled utility room.

Based on record review and interview the hospital failed to ensure a post-anesthesia evaluation was performed which included respiratory function, cardiovascular function, mental status, temperature, pain, nausea/vomiting and post-operative hydration for 6 of 6 patients receiving general anesthesia out of 23 sampled patients (#12, #13, #14, #15, #16, #17). Findings:

Patient #12
Review of the Anesthesia documentation for Patient #12 dated 04/04/11 revealed a seventy-eight year old male who had a repair of an umbilical hernia under general anesthesia. Further review of the anesthesia documentation dated 04/05/11 at 8:00am revealed no documented evidence a complete post anesthesia assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

Patient #13
Review of the Anesthesia documentation for Patient #13 dated 03/27/11 revealed a seventy-one year old female who had an I&D (Incision and Drainage) of a sacral decubitus under general anesthesia. Further review of the anesthesia documentation dated 03/27/11 revealed no documented evidence a complete post-anesthesia assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

Patient #14
Review of the Anesthesia documentation for Patient #14 dated 03/17/11 revealed a seventy-five year old male who had an I&D (Incision and Drainage) of a right calf abscess under general anesthesia. Further review of the anesthesia documentation dated 03/17/11 revealed no documented evidence a complete post-anesthesia assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

Patient #15
Review of the medical record for Patient #15, revealed a 25 year old male admitted to the hospital with the diagnosis of cholelithiasis and was scheduled for a Laproscopic cholestectomy on 03/31/11 under general anesthesia. Review of the post-anesthesia documentation dated 04/01/11 at 10:15am revealed no documented evidence a complete post anesthesia assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

Patient #16
Review of the medical record for Patient #16, revealed a 38 year old female admitted to the hospital on 03/31/11 with the diagnosis of cholelithiasis and was scheduled for a Laproscopic cholestectomy on 04/11/11 under general anesthesia. Review of the post-anesthesia documentation dated 04/03/11 at 1:30pm revealed no documented evidence a complete assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

Patient #17
Review of the medical record for Patient #17, revealed a 59 year old male admitted to the hospital on 03/14/11 with the diagnosis of bladder cancer and was scheduled for a TURBT (Trans Urethral Re-section of a Bladder Tumor) on 03/14/11 under general anesthesia. Review of the post-anesthesia documentation dated 03/14/11 at 1610 (4:10pm) revealed no documented evidence a complete post-anesthesia assessment was performed which included respiratory, cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.

In a face to face interview on 04/05/11 at 20:00pm RN S14 Nurse Manager of OR and PACU (Operating Room and Post-Anesthesia Care Unit) and RN S3 Assistant DON (Director of Nursing) indicated one CRNA (Certified Registered Nurse Anesthetist) is employed by the hospital and the others are contracted. Further both indicated CRNA S18 and himself (RN S14) had been working to include a more comprehensive assessment; however neither were aware of the requirements which included cardio, mental status, temperature, pain nausea/vomiting, post-op hydration and temperature.