HospitalInspections.org

Based on medical record review, document review and interview post anesthesia care unit (PACU) nursing staff did not follow the facility's standard of practice in assessing patients utilizing the Aldrete Scoring System (standard of care assessment tool used to determine when patients are ready for discharge from the PACU) prior to transfer to next level of care in 1 of 22 cases reviewed. Additionally, the hospital policy did not address the frequency of scoring or the score required prior to transfer. These lapses in post-operative assessment and hospital policy potentially place patients at increase risk for poor outcomes after discharge from PACU.

Findings include:

Review of Nursing PACU Aldrete Assessment dated 6-17-16 for Patient #1 revealed Aldrete assessments were performed by nursing staff in PACU, along with vital signs at 4:55 PM, 5:00 PM, 5:05 PM and 5:10 PM. At 5:10 PM the patient had a score of 9. At 6:27 PM the patient was transferred to an inpatient unit.

Interview with Staff #5 and Staff #8 (PACU nurses) on 8-31-16 at 11:00 AM revealed Aldrete assessments should be performed with every vital sign assessment and that a score of 10 must be met in order for patient to be discharged from PACU. If Aldrete score is less than 10 at final assessment, anesthesia must be called to re-evaluate the patient and decide if patient can be moved to next level of care.

Interview with Staff #3 and Staff #15 (OR and PACU managers) on 9-1-16 at 11:00 AM verified that no further Aldrete assessments could be found in the medical record of Patient #1 after 5:10 PM and that this assessment should have been performed by nursing staff with every vital sign assessment and prior to discharge from PACU.

Interview with Staff #7 (Educator OR/PACU) on 9-1-16 at 11:45 AM revealed an Aldrete score of 10 for is expected prior to the discharge of a pediatric patient from the PACU and that an Aldrete scoring assessment should have been done on Patient #1 prior to discharge from the PACU.

Review of the Standard of Care Post Anesthesia-PACU Phase I #SS.24 policy, last revised 2-16-15, revealed that numeric scoring will be completed throughout the PACU stay at determined intervals and that despite an Aldrete score of 10, the patient may merit continued close observation.This policy does not define the time schedule of "determined intervals" or specific discharge criteria.