HospitalInspections.org

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: : K211, K914 and K918.

Based on document review and interview the critical access hospital (CAH) failed to document that patients were discharged in the company of a responsible adult for 2 of 3 same day surgery (SDS) patient records (P1, P3) reviewed.

Findings include:

Documentation was lacking to indicate P1 left in the company of a responsible adult upon discharge. P1 had a colonscopy (view of the colon) on 4/30/18, with IV sedation administered.

Review of P3's electronic medical record lacked documentation that P3 was discharged with a responsible adult. P3 had a hydrocelectomy (surgery to remove a fluid filled sac) on 4/25/18, and received general anesthesia.

During documentation review, the Health Information manager was present and confirmed on 5/1/18, at 2:00 p.m. that documentation was missing to verify P1 and P3 were discharged with another responsible adult.

Review of the policy titled, Monitoring of Patients Receiving Conscious Sedation, revision date 7/2017, indicated that upon discharge "Patient may not drive for 24 hours after receiving IV [intravenous] sedation, so a responsible driver must take the patient home.