HospitalInspections.org

Based on staff interview and medical record review the CAH (Critical Access Hospital) failed to ensure 6 or 7 outpatient surgical patients records (Patients 16, 17, 18, 19, and 20) contained evidence that the physicians completed and documented an examination of the patient immediately before surgery to determine the risk of the procedure. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 2/7/18 to 6/20/18 was 30.

Findings are:

A. Interview on 7/9/18 at 4 PM with the DON (Director of Nursing) revealed the only surgical procedures performed at the facility were colonoscopies (flexible tube inserted into the anus to view the colon) and endogastroduodenoscopies (tube inserted into the mouth to view the esophagus, stomach, and intestine). The procedures were performed by a general surgeon. Anesthesia was provided by a contract CRNA (Certified Registered Nurse Anesthetist).

B. Interview with the CRNA on 7/10/18 at 10 AM revealed that a "deep sedation" was used on the patients with a combination of Fentanyl (narcotic medication), Versed (sedative medication) and Propafol (sedative).

C. Review of Patient 16's medical record on 7/11/18 at 4:30 PM revealed the patient had a colonoscopy and endogastroduodenoscopy due to pharyngoesophageal dysphagia (difficulty swallowing due to weakness in throat muscles) abdominal pain, epigastric pain (upper abdominal pain), and unintentional weight loss. Patient 16's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

D. Review of Patient 17's medical record on 7/11/18 at 3:04 PM revealed the patient had an endogastroduodenoscopy for stomach and abdominal pain. Patient 17's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

E. Review of Patient 18's medical record on 7/11/18 at 4:40 PM revealed that the patient had a colonoscopy. Patient 18's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

F. Review of Patient 19's medical record on 7/11/18 at 4:45 PM revealed the patient had an colonoscopy and endogastroduodenoscopy for difficulty swallowing, abdominal discomfort, and hematochezia (passing of red blood through the anus). Patient 19's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

G. Review of Patient 20's medical record on 7/10/18 at 4 PM revealed the patient had a colonoscopy and endogastroduodenoscopy due to abdominal pain. Patient 20's medical record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

H. Interview with the HIM (Health Information Management) Director 7/11/18 at 4:25 PM confirmed the surgical records did not contain documentation by the surgeon of evaluation for surgical risk before the procedure was performed.