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ROTHMAN ORTHOPAEDIC SPECIALTY HOSPITAL LLC
PRE-ANESTHESIA EVALUATION
Tag No.: A1003
Based on review of medical records (MR), review of facility policy, and interviews with staff (EMP), it was determined the facility failed to complete and document the anesthesia presurgical evaluation for one (1) of one (1) medical record reviews. (MR1)
Findings include:
Review on January 7, 2025, of facility policy "Anesthesia Responsibilities" approved August, 2023, revealed "... Documentation of preoperative and postoperative anesthesia visits must be done on the post anesthesia evaluation sheet ..." Further review of the policy revealed no provision for the documentation of an anesthesia preoperative assessment.
Review on January 7, 2025, of physician documentation "Anesthesia Preoperative Assessment" dated September 11, 2024, revealed no documentation the HEENT (Head, Ears, Eyes, Nose, Throat) was completed by the anesthesia provider prior to surgery.
Interview on January 7, 2025, at approximately 10:50AM with (EMP1) confirmed the anesthesia preoperative assessment was not documented in MR1.