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Based on record review, physician and staff interview there was no documentation by both certified registered nurse anesthetist (CRNA) #1 and Anesthesiologist #2 for the medical interventions provided to one of one Patient #1 who remained in Post Anesthesia Care Unit (PACU) for five hours with unstable blood pressures in February 2011.

The findings are as follow:

Patient #1 was admitted to Surgical Day Care for an elective right inguinal hernia repair on 02/23/11. Patient #1 had liver failure and was a candidate for a liver transplant.

Review of the PACU documentation indicated Registered Nurse #1 documented vasopressor medications were administered by CRNA #1 at the time of transfer of care into PACU.

Review of the PACU Nursing Notes indicated Patient #1 arrived in PACU at 10:15 AM.

At 10:20 AM, RN #1 documented CRNA #1 administered Ephedrine 10 milligrams by intravenous injection to Patient #1.

CRNA #1 documented the administration of the Ephedrine on the Anesthesia Record instead of in the PACU Note or Progress Note. CRNA #1 further documented Patient #1 was released to PACU at 10:28 AM.

Continued review of the PACU Nursing Note indicated on 02/23/11 at 11:10 AM, Patient #1's blood pressure dropped to 77/50. Anesthesiologist #2 was consulted.

There was no documentation in the medical record for the numerous interventions provided to Patient #1 by Anesthesiologist #2 during the five hour period until Patient #1 was urgently sent for a CT scan.

Anesthesiologist #2 said Patient #1's blood pressure was a little low, given ephedrine and Patient #1 responded to the medication. Anesthesiologist #2 said the CRNA might have been there. Anesthesiologist #2 said Patient #1's blood pressure dropped again and Hespan was given which is a volume expander. Anesthesiologist #2 said Surgeon #1 did not think there was any bleeding from the surgery. Anesthesiologist #2 said there were no obvious signs of bleeding, no tachycardia or abdominal guarding or tenderness and if blood was present in the perineum Patient #1 would be very uncomfortable. Anesthesiologist #2 said on second examination, Patient #1's abdomen was distended. Anesthesiologist #1 said when the arterial line and central lines were inserted, Patient #1's blood was like water. Anesthesiologist #2 said Patient #1's hemoglobin and hematocrit were low indicating Patient #1 was bleeding. Anesthesiologist #1 said Patient #1 needed to go to the operating room but Surgeon #1 wanted to obtain a CT scan.

Patient #1 was then transferred back to the operating room for an intraabdominal bleed.

Surgeon #1 failed to document the acknowledgement of Patient #1 low platelet count of 101 ( normal values range between 150 to 400) prior to Patient #1's surgery.