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A. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure the ambulatory surgery patient who underwent intravenous (IV) sedation was discharged into the care of a responsible adult, as required by policy.

Findings include:

1. Hospital policy titled, "Discharge Criteria", reviewed date 5/29/13, required, "9. Responsible adult will be with the patient when discharged if the patient has received IV sedation or general anesthesia."

2. Pt. #1's clinical record was reviewed on 8/8/13 at 10:00 AM. Pt. #1 was a 56 year old female, admitted on 3/2/13, for "left foot deformity correction". Pt. #1's anesthesia record dated 3/2/13 included an anesthesia start time at 9:03 AM and end time at 11:38 AM. A post operative note dated 3/2/13 at 12:19 PM, was written by the Anesthesiologist (MD #2) and included, "... tolerated MAC [monitored anesthesia care] well with no complications... "

3. Pt. #1's clinical record did not include documentation that Pt. #1 was discharged into the care a responsible adult.

4. A phone conversation was conducted with the Registered Nurse (E #2) who discharged Pt. #1 from recovery phase II on 3/2/13. E #2 stated she did not recall Pt. #1. E #2 stated it is the practice not to discharge anyone who does not have a responsible adult to take them home, but the person picking up the patient is not documented.

B. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure tourniquet use was documented in the intraoperative nursing note, as required by policy.

Findings include:

1. Hospital policy number 660.063, revised August 2010, titled, "Pneumatic Tourniquet 1500 Pneumatic Tourniquet 2000"", was reviewed on 8/8/13 at 10:30 AM. The policy required, "Patient assessments... related to use of a pneumatic tourniquet should be documented. 1. The SFH Perioperative Intraoperative Nursing note should be used to document patient care..."

2. Pt. #1's clinical record was reviewed on 8/8/13 at 10:00 AM. Pt. #1 was a 56 year old female, admitted on 3/2/13, for "left foot deformity correction". Pt. #1's anesthesia record dated 3/2/13 included tourniquet start time at 10:24 AM and end time 11:21 AM.

3. On 8/8/13 at 11:30 AM, an interview was conducted with the Nurse Educator for Surgical Services (E #3). E #3 stated that the nursing notes for tourniquet application were missing from the record.

A. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure the surgical consent form, signed by the patient, documented the surgical procedure the patient received.

Findings include:

1. Hospital policy number 1500.40, revised May 2010, titled, "Informed Consent" was reviewed on 8/8/13 at 11:00 AM. The policy required, "Any health care relationship, treatment... with a known or appreciable risk to the patient requires documented evidence of an informed consent form executed by the patient or legally authorized representative... The responsibility for the informed consent discussion for health care treatment or procedure (treatment) always rests with the physician who will be performing the health care treatment..."

2. Pt. #1's clinical record was reviewed on 8/8/13 at 10:00 AM. Pt. #1 was a 56 year old female, admitted on 3/2/13, for left foot deformity correction. Pt. #1's operative report dated 3/2/13, included the pre and post operative diagnosis: "1. Cyst, lateral left ankle. 2. Possible peroneal tendon damage. 3. Lateral ankle instability". The surgical procedures performed were: "1. Arthrotomy, lateral left ankle, with excision of cyst. 2. Primary repair of peroneus brevis tendon, left ankle. 3. Lateral ankle stabilization, modified Brostrom, lateral left ankle. "

3. Pt. #1's signed consent was for a "Bunionectomy (Metatarsal Osteotomy/ Phalangeal Osteotomy) left foot and exploration of lateral ankle". A Bunionectomy was not diagnosed, planned, or performed. The consent did not include Arthrotomy, tendon repair, or ankle stabilization, which were diagnosed and performed.

4. An interview with MD #1 was requested on 8/8/13 at 8:45 AM, 11:30 AM, and 2:35 PM, but the hospital was unable to contact MD #1, and an interview was not conducted.

5. On 8/8/13 at 11:30 AM, an interview was conducted with the Nurse Educator for Surgical Services (E #3). E #3 stated that the Bunionectomy consent included exploration of lateral ankle for which tendon repair would qualify. E #3 stated that a Bunionectomy may have been planned earlier, but was later changed to a tendon repair. E #3 did not know why the consent form was not changed.

B. Based on document review and interview, it was determined, for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure the surgeon (MD #1) signed the consent form prior to performing the procedure.

Findings include:

1. Hospital policy number 1500.40, revised May 2010, titled, "Informed Consent" was reviewed on 8/8/13 at 11:00 AM. The policy required, "The responsibility for the informed consent discussion for health care treatment or procedure (treatment) always rests with the physician who will be performing the health care treatment... The informed consent discussion for outpatient surgery must occur prior to the patient's arrival at the hospital..."

2. Pt. #1's clinical record was reviewed on 8/8/13 at 10:00 AM. Pt. #1 was a 56 year old female, admitted on 3/2/13, for left foot deformity correction. Pt. #1's foot surgery took place on 3/2/13 between 10:00 AM and 11:30 AM. Pt. #1's consent for a Bunionectomy was signed by the Surgeon/Podiatrist (MD #1) on 3/2/13 at 11:30 AM, after the surgery was finished.

3. An interview with MD #1 was requested on 8/8/13 at 8:45 AM, 11:30 AM, and 2:35 PM, but the hospital was unable to contact MD #1, and an interview was not conducted.

4. Surgery Department & OR Committee meeting minutes for 2013 were reviewed on 8/8/13 at 10:55 AM. The 6/4/13 minutes included, " Consents should be signed by the surgeons prior to the procedure... "

5. On 8/8/13 at 11:30 AM, an interview was conducted with the Nurse Educator for Surgical Services (E #3). E #3 stated that the Surgeon explains the procedure to the patient before the surgery, but does not always sign the consent at the same time.