HospitalInspections.org

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Based on document review, Medical Record review and interview, in six (6) of fourteen (14) Medical Records reviewed, the Medical Staff did not update patients' History & Physical (H&P) Examinations prior to anesthesia administration and surgery.

The lack of an updated History & Physical potentially placed patients at increased risk for intra- or post-operative complications.

Findings included:

Review of Patient #15's Medical Record identified the following information: This 40-year-old female was scheduled for a diagnostic arthroscopy of the right hip with intra-operative injections under general anesthesia. The patient was seen in pre-surgical testing on 10/11/18 and a History & Physical was completed by the Nurse Practitioner. The Surgeon co-signed the History & Physical on 10/23/18, twelve (12) days after the original History & Physical was done. The patient returned on 11/06/18 and underwent surgery fourteen (14) days later. However, there was no updated examination of the patient documented by the Surgeon prior to surgery.

Review of Patient #11's Medical Record identified the following information: This 51-year-old female was scheduled for reversal of a colostomy under general anesthesia. The patient was seen in pre-surgical testing on 10/24/18 and a History & Physical was completed by the Nurse Practitioner. The Surgeon co-signed the History & Physical the next day on 10/25/18. The patient returned on 11/07/18 and underwent surgery thirteen (13) days later. However, there was no updated examination of the patient documented by the Surgeon prior to surgery.

The same lack of updated History & Physicals was found in the Medical Records for Patients #12, #13, #14 and #19 for the review periods of 11/07/18 and 11/08/18.

These findings were confirmed with Staff A (Director), Staff B (Chief), and Staff C (Surgical Physician Assistant) at 2:30PM on 11/08/18.

The facility's "Rules and Regulations of the Medical Staff" last revised April 7, 2017, stated the following: "...medical H&P examinations shall be completed and documented for each patient no more than 30 days before or 24 hours after admission ... if a completed H&P examination has been obtained within 30 days before admission ... an updated examination including any changes in the patient's condition or absence thereof must be completed and documented ... prior to surgery or a procedure requiring anesthesia services ... when a H&P examination [is] not completed before a surgical procedure ... the procedure shall be canceled ...".