HospitalInspections.org

Based on medical record review and interview, the facility failed to document in the medical record an update of a history and physical prior to surgery requiring anesthesia services for one patient (#1) of five sampled patients.

The findings included:

Patient #1 was admitted to the facility on June 17, 2009, with diagnoses including Osteoarthritis. Medical record review of a history and physical dated June 11, 2009, revealed, "...right total hip...Informed consent discussed...including risks benefits...potential complications...anesthesia..." Continued review revealed no documention regarding any change(s) and/or lack of change(s) in the patient's condition between June 11, 2009, and June 17, 2009.

Interview with the Chief Operating Officer on September 8, 2010, at approximately 1:05 p.m., in a conference room, confirmed the facility failed to document in the medical record an update of the history and physical for Patient #1 on June 17, 2009.

C/O: #26625