HospitalInspections.org

Based on medical record review, document review and interview, the facility did not ensure an adequate discharge plan was in place for 1 of 15 patients who underwent outpatient surgery (Patient #1). Lack of an adequate discharge plan could result in a negative patient outcome.

Findings include:

Review of the medical record dated 9/29/16 revealed Patient #1 underwent outpatient emergent surgery to repair left eyelid laceration and tear of left lacrimal ducts.

Review of the anesthesia report dated 9/29/16 revealed the anesthesia plan as "general anesthesia". Medications administered intraoperatively included Propofol, Versed, Fentanyl and Ondansteron.

Review of policy and procedure titled: Discharge of Patients who have Received Anesthesia/Moderate Sedation - Policy # GM 10 last revised 7/16 revealed the following:
Discharge:
A. There are two mechanisms by which a patient may be discharged from a post anesthesia care, clinical or procedure area after receiving anesthesia.

2. Patient meets Standardized Discharge Criteria. The patient may be discharged from the post anesthesia recovery area, clinical or procedure area if he/she has attained a Post Anesthesia Recovery (PAR) of 9-10 or is at pre-procedure baseline. *Outpatients must be accompanied by a responsible adult.

Review of the medical record dated 9/29/16 for Patient #1 revealed the patient was discharged to home postoperatively via taxi cab and without a responsible adult in attendance.

Staff # 1 verified that documentation in the medical record reflected the patient was discharged via taxi and without a responsible adult following outpatient surgery on 9/29/16.