HospitalInspections.org

Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 6 of 6 discharged surgical patients (Patients 26, 27, 28, 29, 30 and 31). This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries performed from 2/5/18 to 5/9/18 was 39.

Findings are:

A. Review of Patient 26's medical record (5/16/18 at 8:55 AM) revealed the patient had a laparoscopic cholecystectomy (specialized technique to remove the gallbladder that avoids the long incision used in open surgery) on 5/9/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (1:14 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 27's medical record (5/16/18 at 9:05 AM) revealed the patient had a inguinal hernia (tissue protrudes through a weak spot in the lower abdominal muscles) repair on 4/27/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (11:32 AM) to evaluate the risk of the procedure to be performed.

- Review of Patient 28's medical record (5/16/18 at 9:20 AM) revealed the patient had a rotator cuff (a group of muscles and their tendons that act to stabilize the shoulder) repair on 3/27/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (9:02 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 29's medical record (5/16/18 at 9:30 AM) revealed the patient had a tonsillectomy with adenoidectomy (surgical procedure to remove the tonsils and adenoids) on 2/16/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (9:09 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 30's medical record (5/16/18 at 9:40 AM) revealed the patient had a left total knee replacement on 2/5/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (4:41 PM) to evaluate the risk of the procedure to be performed.

-Review of Patient 31's medical record (5/16/18 at 10:00 AM) revealed the patient had a left side hydrocelectomy (removal of collected fluid in the membrane surrounding the testes) on 4/17/18. The physician signed the form titled "Physician Preoperative Patient Assessment" with no evidence of the time of examination documented to ensure the examination took place before surgery (11:22 AM) to evaluate the risk of the procedure to be performed.

B. Interview with the OR (Operating Room) Supervisor (5/17/18 at 9:00 AM) revealed the facility lacked a policy and procedure for the form titled "Physician Preoperative Patient Assessment" and confirmed the above medical records lack the evidence of the time of the patient examinations completed by the physicians immediately before surgery to evaluate the risk of the procedure to be performed.