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Based on review of facility complaints received from ED Pts and interview with staff, the facility failed to ensure there is a response letter sent to the complainant with description of findings and resolution, in 2 of 7 complaints reviewed. This deficiency directly affected 2 C (N and O), and potentially affects all future complainants.

Findings include:

Review on 4/23/14 at 12:00 PM of facility P&P titled Resolution of Patient Complaints (Grievance), dated 6/12, it states under #11. "Those actions, as appropriate for patient to know, will be relayed to the patient by the department director and/or director of social services or designee in a letter to the patient."

Per review of C N's complaint on 4/23/14 at 12:00 PM, there is no evidence of a response letter sent to C N with a description of the findings and resolution to the concerns. This is confirmed in interview with DQ C on 4/23/14 at 1:00 PM.

Per review of C O's complaint on 4/23/14 at 12:10 PM, there is no evidence of a response letter sent to C O with a description of the findings and resolution to the concerns. This is confirmed in interview with DQ C on 4/23/14 at 1:00 PM.

Based on interview with staff, the facility failed to ensure SSIs are tracked for implantable devices. This deficiency potentially affects all surgical patients receiving implantable devices.

Findings include:

According to the CDC, (as published in January 2013), infection surveillance data is based on categories: With Superficial Surgical Site Infections (SSI) where the incision goes through the skin and subcutaneous tissue (tissue layer under the skin), infections can occur within 30 days. With Deep incision SSIs (incision goes through fascia and muscle tissues) and Organ/Space infections (incision goes through all layers of tissue to the organ space), infections can occur within 30-90 days. Implants are included in the 30-90 day category.

Per interview with IP M on 4/23/14 at 1:20 PM, the facility is not tracking SSI related to implants. IP M stated the facility follows CDC guidelines.

Based on MR review, review of MD credential files and interview with staff, the facility failed to ensure H&P are authenticated by the MD, H&P Updates are completed prior to surgical procedures and MDs do not perform procedures they are not privileged to perform. The cumulative affect of this deficiency affects all 7 of 10 Pts (2, 4, 5, 6, 8, 9 and 10), with MRs reviewed and potentially affects all 22 Pts receiving surgical services during survey.


Findings include:

In 4 of 10 MR, the facility failed ensure H&Ps are authenticated by the MD, in 4 of 10 surgical MRs. See tag A358.

In 4 of 10 MR, the facility failed ensure H&P Updates, for surgery, are completed prior to the procedure. See tag A359.

In 2 of 10 MD credential files reviewed, the facility failed to ensure MDs are performing surgical procedures that they are privileged to perform. See tag A363.

Based on MR review and interview with staff, the facility failed ensure H&Ps are authenticated by the MD, in 4 of 10 surgical MRs (2, 4, 9 and 10). This deficiency directly affects Pts 2, 4, 9 and 10, and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Review on 4/24/14 a 11:05 AM of the facility P&P Medical Staff Completion of Records, revised 9/13, it states under A. History and Physical "...Properly privileged allied health professionals may perform /update the H&P so long as the allied health professional is under the supervision of, or appropriately delegated by, a specific qualified MD or DO who is accountable for patient's H&P. The physician responsible for the patient's care shall counter sign with H&P when it has been records by a non-physician."

Pt #2's MR review on 4/24/14 at 9:05 AM revealed Pt #2 had surgery in perineum area on 1/9/14. The H&P conducted on 1/3/14, by a PA, is not authenticated by the MD. This is confirmed in interview during MR review with RN E, stating the H&P should have been authenticated the day of surgery.

Pt #4's MR review on 4/24/14 at 10:00 AM revealed Pt #4 had shoulder surgery on 1/31/14. The H&P conducted on 12/21/13, by a PA, is not authenticated by the MD. This is confirmed in interview during MR review with RN E, stating the H&P should have been authenticated the day of surgery.

Pt #9's MR review on 4/24/14 at 11:40 AM revealed Pt #9 had foot surgery on 3/13/14. The H&P conducted on 2/20/14, by a PA, is not authenticated by the MD. This is confirmed in interview during MR review with RN E, stating the H&P should have been authenticated the day of surgery by the MD.

Pt #10's MR review on 4/24/14 at 12:00 PM revealed Pt #10 had knee surgery on 1/10/14. The H&P conducted on 12/30/13, by a PA, is not authenticated by the MD. This is confirmed in interview during MR review with RN E, stating the H&P should have been authenticated the day of surgery.

Based on MR review and interview with staff, the facility failed to ensure H&P Updates, for surgery, are completed prior to the procedure, in 4 of 10 surgical MRs (2, 4, 5, and 10). This deficiency directly affects Pts 2, 4, 5 and 9, and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Per review on 4/23/14 at 1:30 PM of the Medical Staff R&R, dated 8/22/07, it states under 8. "Patients for surgery shall ordinarily have a history and physical examination recorded on the chart prior to surgery."

Review on 4/24/14 a 11:05 AM of the facility P&P Medical Staff Completion of Records, revised 9/13, it states under A. Surgery or Procedure Requiring Anesthesia Services 2. "When using an H&P that was performed up to 30 days prior to the surgery/procedure, the update must be performed and documented prior to surgery..."

Pt #2's MR review on 4/24/14 at 9:05 AM revealed Pt #2 had surgery in perineum area on 1/9/14. The H&P Update, on the date of surgery is timed 11:11 AM. The surgery started at 9:10 AM. This is confirmed in interview during MR review with RN E, stating the H&P Update should have been timed prior to the procedure.

Pt #4's MR review on 4/24/14 at 10:00 AM revealed Pt #4 had shoulder surgery on 1/31/14. The H&P Update, on the date of surgery is not timed. This is confirmed in interview during MR review with RN E, stating the H&P Update should have been timed prior to the procedure.

Pt #5's MR review on 4/24/14 at 10:25 AM revealed Pt #5 had finger surgery on 2/19/14. The H&P Update, on the date of surgery is not dated and timed. This is confirmed in interview during MR review with RN E, stating the H&P Update should have been timed prior to the procedure.

Pt #10's MR review on 4/24/14 at 12:00 PM revealed Pt #10 had knee surgery on 1/10/14. The H&P Update, on the date of surgery is timed 11:15 AM. The surgery started at 9:22 AM. This is confirmed in interview during MR review with RN E, stating the H&P Update should have been timed prior to the procedure.

Based on MR review and interview with staff, the facility failed to ensure MDs are performing surgical procedures that they are privileged to perform, in 2 of 10 MD (J and K) credential files. This deficiency directly affects 2 of 10 Pts (6 and 8) and potentially affects 22 patients receiving surgical procedures during survey.

Findings include:

Per review on 4/24/14 at 1:30 PM of Medical Staff By-laws, dated 9/25/13, it states under Article VI Clinical Privileges 6.1 Exercise of Privileges. " The granting of Clinical Privileges shall entitle the individual to exercise only those Clinical Privileges specifically granted to him or her by the Board of Directors, except as provided in this Article VI."

Per review of the surgery schedule from 12/1/13 to 4/23/14 the following procedures were performed by MD J:

A cysto (cystoscopy, use of scope to view organs) on 12/9/13, 12/16/13 (Pt 8), 12/30/14, 1/6/14, 1/27/14, 2/3/14, 2/17/14, 3/3/14, 3/10/14, 3/11/14, 3/17/14, and 3/18/14.

Myomectomy (removal of muscle tissue) on 1/27/14.

Clitorial Cystectomy (removal of cyst on clitoris) on 3/10/14

Removal of endometriosis (removal of excess uterine tissue) on 1/6/14, 2/11/14 (Pt #6), 2/18/14,

Hydrodistenstion (filling of bladder to check for leaks) on 1/20/14, 12/2/13

Rectocele (protrusion of rectal wall into vaginal wall) repair on 12/30/13

Dilatation and Curettage for removal of placenta (dilate and manual removal of placenta after birth) on 12/10/13.

Per review of privileges granted on 10/13 for MD J, the above procedures are not on the privilege list. This is confirmed in interview with MD D on 4/24/14 at 2:00 PM, adding the privilege cystotomy appeared to be in error and should have been cystoscopy, and the remaining items are not on the privilege list to select or were not selected by the MD, therefore not approved. MD D stated there usually is a "Core" privilege authorization, that may include some of the above procedures, but there is no "Core" privilege authorization in MD J's credential file.

Per review of the surgery schedule from 12/1/13 to 4/23/14 a Trans-vaginal sling (to prevent prolapse of organs) procedure is listed as performed by MD K on 12/9/13.

Per review on 4/24/14 at 2:00 PM of privileges granted in 4/13 for MD K, the trans-vaginal sling is not on the privilege list. There is no temporary privilege to perform the trans-vaginal sling procedure.

This is confirmed in interview with MD D on 4/24/14 at 2:00 PM adding the procedures should not be performed by the MD's if they are not on their privilege list.

Based on MR review and interview with staff, the facility failed to ensure all orders, including verbal orders, are authenticated by the MD with a legible signature, date and time, in 3 of 10 MRs reviewed. This deficiency directly affects Pts 5, 6 and 9 and potentially affects all 22 Pts receiving surgery during survey.

Findings include:

Review on 4/24/14 a 11:05 AM of the facility P&P Medical Record Entries and Corrections, revised 8/11, it states "...All hand written entries in the medical record shall be legible, dated (including year), timed (military time) and authenticated."

Pt #5's MR review on 4/24/14 at 10:25 AM revealed the Out-Pt Pre-Operative orders completed by the PA on 2/19/14 are not authenticated by the MD with a date and time. This is confirmed in interview with RN E during MR review, adding the authentication requires a signature, date and time.

Pt #6's MR review on 4/24/14 at 10:40 AM revealed the Anesthesia PACU orders completed by the CRNA on 2/11/14 is not timed. This is confirmed in interview with RN E during MR review, adding the order requires a signature, date and time.

Pt #9's MR review on 4/24/14 at 11:40 AM revealed the Pre-Operative orders completed on 3/13/14 have an illegible time, and additions to the orders, written as a Verbal Order are not authenticated by the MD. This is confirmed in interview with RN E during MR review, adding the authentication requires a signature, date and time.

Based on observation, MD credential file review, MR review and interview with staff, the facility failed to ensure MD staff did not perform procedure they are not credentialed to perform, staff followed surgical P&Ps, verbally state and document the skin prep is dry, and the PON is completed after the procedure is completed. The cumulative affect of this deficiency affects all 10 Pts with MRs reviewed and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

In 2 of 10 MD credential files reviewed the facility failed to ensure MDs do not perform procedures they are not credentialed to perform. See tag A945.

In 2 of 5 staff observed, the facility failed to ensure staff following facility policy regarding PPE, IV medication administration and skin prep; verbally state skin prep is dry and document what prep is used and that it is dry prior to draping. See tag A951.

In 5 of 10 MRs reviewed, the facility failed to ensure the MD signed, dates and times the surgical consent form prior to the procedure. See tag A955.

In 3 of 10 MRs reviewed, the facility failed to ensure the PON is completed after the procedure. See tag A959.

Based on review of facility surgical logs, review of MD credential files and interview with staff, the facility failed to ensure MDs do not perform procedures they are not credentialed to perform, in 2 of 10 MD credential files reviewed (J and K). This deficiency directly affected Pts 2 of 10 Pts (6 and 8) MR selected from the surgery schedule and potentially affects all 22 Pts having surgery during survey.

Findings include:

Per interview with RN E on 4/23/14 at 10:00 AM the facility has a scheduling system that does not allow a MD to perform a procedure that is not matched to the MD's privileges. RN E stated if the procedure is not on the privilege list, a request is made to the Chief Medical Staff to grant temporary privileges.

Per review of the surgery schedule from 12/1/13 to 4/23/14 the following procedures were performed by MD J:

A cysto (cystoscopy, use of scope to view organs) on 12/9/13, 12/16/13 (Pt #8), 12/30/14, 1/6/14, 1/27/14, 2/3/14, 2/17/14, 3/3/14, 3/10/14, 3/11/14, 3/17/14, and 3/18/14.

Myomectomy (removal of muscle tissue) on 1/27/14.

Clitorial Cystectomy (removal of cyst on clitoris) on 3/10/14.

Removal of endometriosis (removal of excess uterine tissue) on 1/6/14, 2/11/14 (Pt #6), 2/18/14.

Hydrodistenstion (filling of bladder to check for leaks) on 1/20/14, 12/2/13.

Rectocele (protrusion of rectal wall into vaginal wall) repair on 12/30/13.

Dilatation and Curettage for removal of placenta (dilate and manual removal of placenta after birth) on 12/10/13.

Per review on 2/24/14 at 10:45 AM, of privileges granted on 10/8/2013 for MD J, the above procedures are not on the privilege list. There are no temporary privileges granted for the above procedures.

This is confirmed in interview with RN E on 4/24/14 at 10:45 AM adding the procedures should not have been allowed if they were not in the scheduling system.


Per review of the surgery schedule from 12/1/13 to 4/23/14 a Trans-vaginal sling (to prevent prolapse of organs) procedure is listed as performed by MD K on 12/9/13.

Per review on 4/24/14 at 2:00 PM of privileges granted in 4/13 for MD K, the trans-vaginal sling is not on the privilege list. There is no temporary privilege to perform the trans-vaginal sling procedure.

The is confirmed in interview with MD D on 4/24/14 at 2:00 PM adding the procedures should not be performed by the MD's if they are not on their privilege list.

No reason was provide by RN E why the system allowed the procedures to be scheduled.

Based on observation, MR review and interview with staff, the facility failed to ensure staff are following facility policy and manufacturer's instructions regarding PPE and skin prep; aseptically administer IV medications, verbally state skin prep is dry and document what prep is used and that it is dry prior to draping, in 3 of 5 staff observed (F, H and L), and in 10 of 10 surgical MRs reviewed (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This deficiency directly affects the observed Pt #1 and potentially affects all 22 patients receiving surgical services during survey.

Findings include:

Per review on 4/23/14 at 11:38 AM of facility policy titled Surgical Skin Prep, revised 8/08 and reviewed 10/11, it states under 4. D. "Wet sponge with chlorhexidine gluconate; scrub skin at incision site with a circular motion in ever-widening circles to the periphery; use enough friction and pressure to remove microorganisms from the skin...G. Wet sponge with Betadine, paint Betadine on skin at incision site with a circular motion in every(sic)-widening circles to the periphery"

Per review on 4/23/14 at 11:39 AM of facility policy titled Surgical Draping, revised 7/13, it states under #1. "After the patient is positioned on the operating table, the surgical prep is completed and allowed to dry (important with alcohol base preps such as "Duraprep"), the scrub technician and the surgeon will aseptically place sterile surgical drapes to adequately cover the patient and surrounding area."

Per review on 4/23/14 at 2:40 PM of manufacturer's instructions titled Use of Betadine for Patient Preoperative Skin Preparation (n.d.) it states "Betadine Solution should be allowed to air dry following application to ensure that povidone-iodine is in contact with the skin long enough to provide full antimicrobial effect."

Per review on 4/24/14 at 8:20 AM of facility policy titled Wearing Apparel, revised 6/12, sates under #5. "Personnel should cover hair and facial hair when in the restricted area of the OR..."

On 4/23/14 between 10:10 AM and 11:00 AM the following was observed:

At 10:28 AM RN F, CRNA H and MD L did not have all their hair covered by a bonnet.

At 10:28 AM CRNA H did not wipe the IV port prior to injecting the medications fentanyl (analgesic, versed (amnesia medication), and propofol (sedative). Per interview with RN E on 4/23/14 at 11:00 AM staff should clean the IV port prior to injecting each medication.

At 10:29 AM MD L used one alcohol wipe to clean multiple injection sites for numbing medications on both of Pt #1's right and left foot. Per interview with RN E on 4/23/14 at 11:00 AM RN E agreed staff should use a new alcohol wipe for each injection site.

At 10:44 AM RN H washed Pt #1's entire left foot scrubbing back and forth with chlorhexidine gluconate (antibacterial soap), rather than starting at the incision site (near great toe) and wiping in a circular motion outward per policy. RN H applied Betadine to Pt #1's left foot, starting at the incision site near the great toe, wiping towards the heel, brought back the sponge to the toes and wiped the top of the foot to the ankle and proceeded to wipe back to the toes on the top, side and bottom of foot, rather than starting at the incision site and wiping in a circular motion outward circular motion per policy. OR Tech G did not wait for the prep to dry and placed a sterile towel over the foot. RN H prepped Pt #1's right foot in the same manner as the left foot and OR tech G immediately placed the drape on the foot with out allowing the prep to dry, and without the surgeon present in the OR per policy. No staff stated verbally the skin prep is dry prior to draping. Per interview with RN E on 4/23/14 at 11:00 AM, staff are to follow prepping technique per policy, follow manufacturer's instructions on dry time and verbally state the prep is dry before draping.

Per review of Pt MRs #'s 1 through 10 on 4/24/14 between 8:00 AM and 10:25 AM there is no documentation the skin prep is dry prior to draping for surgical procedures. Pts #4, 5 and 10's MRs indicated an alcohol based skin prep was used. Pt #2's MR revealed there is no documentation of what skin prep is used prior to surgery This is confirmed in interview with RN E, adding the facility uses both alcohol based and non-alcohol based skin prep, and did not know they should document in the MR the skin prep is dry prior to draping.

Based on MR review and interview with staff, the facility failed to ensure the MD signed, dates and times the surgical consent form prior to the procedure, in 6 of 10 MR (2, 3, 4, 5, 7 and 10). This deficiency directly affects Pts 2, 3, 4, 5, 7 and 10, and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Review on 4/24/14 a 11:05 AM of the facility P&P Medical Record Entries and Corrections, revised 8/11, it states "...All hand written entries in the medical record shall be legible, dated (including year), timed (military time) and authenticated."

Pt #2's MR review on 4/24/14 at 9:05 AM revealed Pt #2 had surgery in perineum area on 1/9/14. The surgery started at 9:10 AM, the consent for surgery, attesting risks and benefits were discussed, is timed by the MD at 11:11 AM. This is confirmed in interview during MR review with RN E, stating the consent should be signed, dated and timed by the MD prior to the procedure.

Pt #3's MR review on 4/24/14 at 9:30 AM revealed Pt #3 had two separate abdominal surgeries on 12/5/13 by two separate MDs. The first surgery's anesthesia started at 10:40 AM, the consent for the second surgery, attesting risks and benefits were discussed, is timed by the MD at 11:11 AM. This is confirmed in interview during MR review with RN E, stating the consent should be timed by the MD prior to the procedure.

Pt #4's MR review on 4/24/14 at 10:00 AM revealed Pt #4 had shoulder surgery on 1/31/14. The consent for surgery, attesting risks and benefits were discussed, is not signed, dated and timed by the MD. This is confirmed in interview during MR review with RN E, stating the consent should be signed, dated and timed by the MD prior to the procedure.

Pt #5's MR review on 4/24/14 at 10:25 AM revealed Pt #5 had finger surgery on 2/19/14. The consent for surgery, attesting risks and benefits were discussed, is not dated and timed by the MD. This is confirmed in interview during MR review with RN E, stating the consent should be signed, dated and timed by the MD prior to the procedure.

Pt #7's MR review on 4/24/14 at 10:55 AM revealed Pt #7 had abdominal surgery on 12/11/13. The consent for surgery, attesting risks and benefits were discussed, is not signed, dated and timed by the MD. This is confirmed in interview during MR review with RN E, stating the consent should be signed, dated and timed by the MD prior to the procedure.

Pt #10's MR review on 4/24/14 at 12:00 PM revealed Pt #10 had knee surgery on 1/10/14. The consent for surgery, attesting risks and benefits were discussed, is not timed by the MD. This is confirmed in interview during MR review with RN E, stating the consent should be signed, dated and timed by the MD prior to the procedure.

Based on MR review, and interview with staff, the facility failed to ensure the PON is completed after the procedure, in 3 of 10 MRs (1, 3 and 5) requiring a PON. This deficiency potentially affects all 22 Pt receiving surgical services during survey.

Findings include:

Review on 4/24/14 a 11:05 AM of the facility P&P Medical Record Entries and Corrections, revised 8/11, it states "...All hand written entries in the medical record shall be legible, dated (including year), timed (military time) and authenticated."

Pt #1's MR review on 4/24/14 at 8:20 AM revealed Pt #1 had foot surgery on 4/23/14. The surgery started at 10:50 AM and ended at 11:50 AM. The PON is timed at 10:00 AM, prior to the beginning of the procedure. This is confirmed in interview during MR review with RN E, adding the PON should be timed after the procedure.

Pt #3's MR review on 4/24/14 at 9:30 AM revealed Pt #3 had abdominal surgery on 12/5/13. The surgery started at 11:17 AM and ended at 12:50 AM. The PON is timed at 11:11 AM, during the procedure. This is confirmed in interview during MR review with RN E, adding the PON should be timed after the procedure.

Pt #5's MR review on 4/24/14 at 10:25 AM revealed Pt #5 had finger surgery on 2/19/14. The PON is not dated and time by the MD. This is confirmed in interview during MR review with RN E, adding the PON should be timed after the procedure.

Based on MR review and interview with staff, the facility failed to ensure there are policy and procedures to provide guidance for anesthesia staff. The cumulative affect of this deficiency affects all 10 Pts with MRs reviewed and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Per interview with staff, the facility failed to ensure there are policy and procedures to provide guidance for anesthesia staff. See tag A1002.

Per MR review and interview with staff, the facility failed to ensure the APN is complete and documented after the Pt recovers from anesthesia. See tag A1005.

Based on interview, the facility failed to ensure there are policies and procedures approved by the Governing Body and Medical Staff to serve as guidance for anesthesia services including pre- and post-operative documentation. This deficiency potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Per interview with MD D on 2/24/14 at 2:55 PM, there are no policies for the anesthesia staff to use as guidance for providing anesthesia services, including pre and post-operative documentation.

Based on MR review and interview with staff, the facility failed to ensure the APN is complete, documented after the Pt has recovered from anesthesia and there is guidance for anesthesia staff through policy, in 10 of 10 MRs requiring APN (1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This deficiency affects all 10 Pts with MRs reviewed and potentially affects all 22 Pts receiving surgical services during survey.

Findings include:

Per interview with MD D on 2/24/14 at 2:55 PM, there are no policies for the anesthesia post-op note; no guidance for content or timing of the note.

Pt #1's MR review on 4/24/14 at 8:20 AM revealed Pt #1 had bi-lateral foot surgery on 4/23/14 under MAC. The Anesthesia report indicated the surgery is finished at 11:50 AM, the APN is timed 11:55 AM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature, pain evaluation, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #2's MR review on 4/24/14 at 9:05 AM revealed Pt #2 had surgery in perineum area on 1/9/14 under MAC. The Anesthesia report indicated the surgery is finished at 10:25 AM, the APN is timed 10:35 AM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature, pain evaluation, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #3's MR review on 4/24/14 at 9:30 AM revealed Pt #3 had abdominal surgery on 12/5/13 under General Anesthesia. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #4's MR review on 4/24/14 at 10:00 AM revealed Pt #4 had shoulder surgery on 1/31/14 with a nerve block and General Anesthesia. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature, pain evaluation, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #5's MR review on 4/24/14 at 10:25 AM revealed Pt #5 had finger surgery on 2/19/14 under MAC. The Anesthesia report indicated the surgery is finished at 12:21 PM, the APN is timed 12:30 PM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature, pain evaluation, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #6's MR review on 4/24/14 at 10:40 AM revealed Pt #6 had abdominal surgery on 2/11/14 under General Anesthesia. The Anesthesia report indicated the surgery is finished at 9:41 AM, the APN is timed 9:56 AM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature, pain evaluation, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #7's MR review on 4/24/14 at 10:55 AM revealed Pt #7 had abdominal surgery on 12/11/13 under General Anesthesia. The Anesthesia report indicated the surgery is finished at 9:42 AM, the APN is timed 9:55 AM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note which is missing: Airway patency and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #8's MR review on 4/24/14 at 11:05 AM revealed Pt #7 had abdominal surgery on 2/11/14 under General Anesthesia. The APN does not reflect a comprehensive note which is missing: Airway patency, temperature and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note should include all components of a APN.

Pt #9's MR review on 4/24/14 at 11:40 AM revealed Pt #9 had foot surgery on 3/13/14 under a Spinal Block. The Anesthesia report indicated the surgery is finished at 2:20 PM, the APN is timed 2:50 PM, which is not adequate time for recovery of anesthesia medications and, in part, illegible. The APN does not reflect a comprehensive note which is missing: Airway patency, nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.

Pt #10's MR review on 4/24/14 at 12:00 PM revealed Pt #10 had knee surgery on 1/10/14 under General Anesthesia. The Anesthesia report indicated the surgery is finished at 11:05 AM, the APN is timed 11:35 AM, which is not adequate time for recovery of anesthesia medications. The APN does not reflect a comprehensive note missing: blood pressure, heart rate, respiratory rate, oxygen saturation, airway patency, temperature, pain evaluation,nausea and vomiting and postoperative hydration. This is confirmed in interview during MR review with RN E, agreeing the note is written too soon and should include all components of a APN.