HospitalInspections.org
Bringing transparency to federal inspections
AVERA MARSHALL REGIONAL MEDICAL CTR
No Description Available
Tag No.: C0322
Based on observation, record review and staff interview, the facility failed to ensure that 1 of 2 surgical out-patients (S2) was evaluated for proper anesthesia recovery following surgery.
Findings include:
S2 underwent a surgical procedure under general anesthesia on 6/24/13. The CRNA (certified registered nurse anesthetist) failed to documented a post-anesthesia evaluation note on S2.
Under the section on the Anesthesia Record titled, "Post Anesthesia Note" for S2, there was no documentation.
Review of the hospital's policy titled, Anesthesia Department Services, with a revision date of October 2012, specified under section IV-C Post Anesthesia Evaluation:
1. All patients receiving general, regional or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services.
The CRNA was interviewed at 8:35 a.m. on 6/23/13. He verified that the CRNAs generally do not make notations on out-patient charts.