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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 March 7, 2013
VIOLATION: NURSING SERVICES Tag No: A0385
Based on staff interview, facility policy and procedure, and medical record review the facility failed to ensure RNs (registered nurse) supervise the nursing care for all patients, evaluate patient care needs, patient health status, and patient response to interventions. This deficient practice can potentially effect all patients receiving treatment at this facility.

Findings include:

The facility failed to monitor patient care needs, adjust treatment plans/goals according to patient change in condition, assess vital signs, perform physical assessment, assess health status, and notify physician of patients change of condition.


The cumulative effect of these failures and the serious outcome in response to these failures has potential to effect the health and safety of all patients receiving care at this facility. See A395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, policy and procedure review, and staff interview the facility failed to ensure RN's monitor, assess, and evaluate patients in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially effect all patient's receiving treatment at this facility.

Review on 3/7/13 of Policy--TWHH Patient Care Guidelines--Inpatient Department, last updated 9/2012 revealed the following:
-All physical assessments will be done on critical care patients every 4 hours or as needed and documented in the electronic health record.
-vital signs include blood pressure, pulse, respiratory rate, temperature and pulse oximetry.
-ICU patients should have vitals signs done every hour or more frequently if patient is unstable.
-Post-anesthesia recovery patients will have vital signs done every 15 minutes.
-The Aldrete score will be done by the RN on admission to unit post-general anesthesia or moderate sedation. The Aldrete score will be monitored every 15 minutes for a minimum of one hour and continue until they have reached an Aldrete score of greater than or equal to 8. If the patient is going to be classified as ICU status, the Aldrete score will need to be done every 15 minutes for one hour post-anesthesia or sedation and then the nurse will document "discharged to ICU status".

Review on 3/7/13 of Policy--Medical Record Documentation last revised 6/2011 revealed the following under "Record Content":
-The medical record will contain sufficient data needed to communicate pertinent information to other care providers and contain at least but not limited to the following information: Patient history and assessment findings as appropriate for condition, operative reports, progress notes, reassessment findings, response to therapies.

Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM, reveals the following: on 1/7/13 Pt #1 had a surgical procedure requiring general anesthesia. Pt #1's anesthesia stop time is 4:15 PM. Per Pt #1's physician orders dated 1/7/13 at 4:29 PM, Pt #1 is to have post surgical vital signs performed every 15 minutes until stable, then every 30 minutes for 6 hours. Pt #1's VS taken at 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM, 5:30 PM, 6:15 PM, 7:15 PM, 7:30 PM, 8:30 PM, 9:30 PM, and 10:30 PM do not include temperature. Per Pt #1's VS flowsheet, after the completion of Pt #1's 15 minutes VS's, Pt #1's VS's were only checked every hour and not every 30 minutes for 6 hours, as instructed in physician orders.

On 1/7/13 at 5:30 PM, documentation shows Pt #1 "remains ICU", per Pt #1's Post Anesthesia Recovery Orders dated 1/7/13, "discharge criteria" (from post anesthesia care) lists the following (including but not limited to): Aldrete score of 8, oriented to person, obeys simple commands, moves all extremities as per pre-procedure status, temperature of 36-37.8 Celsius. Review of Pt #1's MR reveals no evidence of Pt #1 meeting discharge criteria prior to placing patient in ICU status. Per interview with COA D (anesthesiologist) on 3/7/13 beginning at 8:50 am, discharge criteria must be met prior to moving patient to "phase 2" or ICU status. COA D confirmed discharge criteria on Post Anesthesia Care Orders form. Per interview with RN E on 3/7/13 beginning at 10:45 am, if patient unresponsive or VS's unstable then patient is to remain in phase 1 (post anesthesia recovery care) and patient receives one on one nursing care; per RN E a focused assessment should be done every 15 minutes during phase 1, once patient is considered ICU (Intensive Care Unit) status RN assessments are done every 4 hours and RN's can have as many as 2 patients in ICU status.

Pt #1's comprehensive RN assessment documented on 1/7/13 at 4:15 PM reveals Pt #1's respiratory pattern is "irregular, shallow, tachypneic". Under the neurological assessment the Glascow Coma scale documented at 4:15 PM shows the following; eye opening "none", verbal response "none", motor response "none"; pupil reaction is documented as "sluggish", and the motor strength scale for all extremities is documented as "no resistance, weak". No assessment documented identifying if Pt #1 is oriented to self. Documentation of a respiratory and neurological re-evaluation of abnormal findings not done until 8:30 PM; 4 hours and 15 minutes later.

Comprehensive RN assessment documented at 8:30 PM reveals the following documentation under neurological assessment Glascow Coma scale(showing no improvement); eye opening "none", verbal response "none", and motor response "abnormal flex". Category under movement/sensation is documented "WDL (within defined limits)", the documentation of "WDL" is inconsistent with previous abnormal findings in regards to Pt #1's motor function..

Per Pt #1's RN assessment at 8:30 PM, no documentation noting a re-evaluation for the following issues; motor strength to assess weakness in all extremities, pupil reaction, and respiratory pattern. RN assessment re-evaluating abnormal findings including Pt #1's level of consciousness is not documented until 1/8/13 at 1:20 am; 4 hours and 45 minutes later. At 1:20 am the Glascow Coma scale showed no improvement, and the documentation listed the following; eye opening "none", verbal response "none", motor response "withdraws/pain".

Per interview with RN E on 3/7/13 beginning at 10:45 am generally eye opening, verbal response, and following commands happens within 1 to 2 hours post surgery using general anesthesia. Per RN E, if a patient's condition is not improved within a couple hours after surgery then RN E would contact the surgeon. Per interview with COA D on 3/7/13 beginning at 8:50 am, if patient is not responsive including verbal response, eye opening, and motor movement within 2 to 3 hours after surgery, the surgeon and anesthesiologist should be notified. Per review of Pt #1's MR, Pt #1's condition did not improve after surgery and there is no evidence that an RN notified the surgeon or the anesthesiologist until early morning on 1/8/13, more than 12 hours after Pt #1's surgery.

1/8/13 at 4:19 am, RN note states, "Pt#1 unable to keep eyes open for any length of time, unable to grasp with left hand, when eyes open pt is looking to right but can follow slowly." Pt is not seen by a nurse practitioner (NP) until 1/8/13 at 6:15 am. NP progress note 1/8/13 at 6:15 am states patient is "very lethargic, difficult to arouse." On 1/8/13 at 7:50 am and 8:10 am physician ordered Narcon IV (opioid reversal agent) with no improvement. 1/8/13 at 11:34 am RN documents under musculoskeletal assessment shows left arm and leg weakness. CT scan to rule out CVA (cerebral vascular accident) not ordered by physician until 3:30 pm, despite documentation of patient having no improvement in mental status post surgery and new symptoms of left sided weakness (documented at 4:19 am and 11:34 am on 1/8/13). MRI of brain done on 1/9/13 confirmed Pt #1 had suffered a CVA.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am, reveals the following: Pt #2's vital signs flow sheet dated 1/3/13 at 1:15 PM, 1:30 PM, 1:45 PM, 2:00 PM do not monitor Pt #2's temperature. Aldrete score post surgery assessed every 15 minutes for 45 minutes and not for a minimum of 1 hour as per policy. No documentation in MR of when Pt #1 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following; Pt #3's temperature and respiratory rate are not consistently monitored post surgery. Pt #3's Aldrete score post surgery shows an assessment every 15 minutes for only 45 minutes and not a minimum of 1 hours as per policy. No documentation in MR of when Pt #3 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following; Pt #4's temperature, pulse, and respiratory rate post surgery are not consistently monitored. Per Pt #4's MR, there is only documentation of 1 Aldrete score assessment post surgery. No documentation in MR of when Pt #4 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following; Pt #5's temperature post surgery is not consistently monitored.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM reveals the following; Pt #6's temperature, respiratory rate, and BP post surgery are not consistently monitored. Pt #6's Aldrete score post surgery shows an assessment every 15 minutes for only 45 minutes. No documentation in MR of when Pt #6 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following; Pt #7's temperature, pulse, and respiratory rate post surgery are not consistently monitored. Per patient orders dated 2/5/13 at 8:30 am, post surgical VS's are as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #7's MR reveals VS's monitored every 15 minutes from 1:30 PM until 3:45 PM, and then not monitored again until 7:45 PM; 3 hours 30 minutes later.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following; Pt #8's temperature and respiratory rate post surgery are not consistently monitored. Pt #8's Aldrete score post surgery shows an assessment every 15 minutes for only 30 minutes. No documentation in MR of when Pt #8 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM reveals the following; Pt #9's temperature and respiratory rate post surgery are not consistently monitored. Per patient orders dated 2/21/13 at 8:00 am, post surgical VS's are as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #9's MR reveals VS's monitored every 15 minutes from 11:15 am to 2:00 PM and then not monitored again until 4:30 PM; 2 hours and 30 minutes later. Pt #9's Aldrete score post surgery shows an assessment every 15 minutes for only 45 minutes. No documentation in MR of when Pt #9 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following; Pt #10's patient orders dated 2/22/13 at 8:30 am, show post surgical VS's as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #10's MR reveals VS's monitored every 15 minutes from 2:25 PM to 4:00 PM and then not monitored until 6:29 PM; 2 hours and 29 minutes later. Pt #10's temperature and respiratory rate post surgery are not consistently monitored. Pt #10's Aldrete score post surgery shows an assessment every 15 minutes for only 45 minutes. No documentation in MR of when Pt #10 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status.

The above findings were confirmed at the time of MR review with QA B and DIM C.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on observation, interview and record reviews, the MR department of the hospital failed to ensure the medical records were complete and comprehensive. This had the potential to affect all patients receiving treatment at this facility.

Findings Include:

The MR department of the hospital, failed to ensure that 9 of 10 Pt's had complete, dated, timed, and authenticated documentation in their medical records. (A 450)

The MR department of the hospital, failed to ensure 10 of 10 Pt's had verbal orders dated, timed, and authenticated by the ordering practitioner. (A 454)

The MR department of the hospital, failed to ensure 10 of 10 Pt's had an updated H & P prior to surgery or a procedure requiring anesthesia. (A 461)

The MR department of the hospital, failed to ensure for 10 of 10 Pt's, that all information necessary to monitor the patient's condition was documented in the Pt's medical record. (A 467)

The cumulative failures of MR department resulted in the hospital's inability to ensure completion of the medical records and include the information necessary to monitor the condition of all Pt's.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on medical record review and policy and procedures the facility failed to ensure all medical records are timed, authenticated, and legible in 9 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,10). This can potentially affect all patient's receiving treatment at this facility.


Per review on 3/7/13 of facility policy titled, Medical Record documentation, last reviewed 6/2011: every entry in the medical record will be dated and timed and authenticated by the person making the entry; the MR will contain sufficient data needed to communicate pertinent information to other care providers including but not limited to the following; operative reports; corrections to the medical record documentation will be accomplished by drawing a single line through the entry with the author's initials, date and "error" recorded in close proximity to the change.

Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM reveals the following: no documentation of time on neurology consult dated 1/10/13; no time, date, or authentication on Pt #1's Heparin Infusion Protocol form, documentation on form states, "Start 1/9/ AM"; no documentation of time on H&P dated 12/20/12.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am reveals the following: no documentation of time on H&P dated 12/28/12.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following: no documentation of time on H&P dated 1/4/13.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following: no documentation of time on the Radiofrequency Catheter Ablation Post Procedure Admission Orders dated 1/8/13, and under location the "ICU" box is marked with a line and then scribbled over and the subsequent box is checked; no documentation of time and authentication on the Cardiac Ablation Procedure Log dated 1/8/13.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following: no documentation of time on H&P dated 1/4/13; the Intraoperative Medical Orders dated 1/8/13; the telemetry orders dated 1/8/13; and, no documentation of time and date on the Post-operative Cardiovascular Surgery Order set.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM reveals the following: on Pt #6's Telemetry Patient Orders form, the "Telemetry Monitoring only" box is crossed out and scribbled over and the subsequent box is checked and there is no documentation of time, date, and authentication on this form or on the Radiofrequency Catheter Ablation Post Procedure admission orders.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following: no documentation of time on Pt #7's post Cardiac Catheterization lab report dated 2/6/13; no documentation of time and authentication on the Procedure Log dated 2/5/13.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following: no documentation of time on the H&P dated 1/22/13 and the Intraoperative Medical Orders form dated 2/12/13. no documentation of time, date, and authentication on Thoracotomy Thorascopy admission pre-procedure orders.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following: no documentation of time on Pt #10's post Cardiac Catheterization lab report dated 2/22/13.

The above findings were confirmed at time of MR review with QM B and DIM C.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on medical record review and policy and procedure review the facility failed to ensure all verbal orders are authenticated in a timely manner in 10 of 10 medical records reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially affect all patient's receiving treatment at this facility.


Per review on 3/7/13 of Medical Staff Rules Regulations page 11: verbal or phone orders should be signed by the appropriately authorized individual who receives and records the order, and the member of the medical staff, house staff, or allied health professional shall date and authenticate all inpatient orders within 48 hours, the authentication must include the date and time the order was signed.

Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM reveals the following: telemetry and medication verbal orders dated 1/7/13 and 1/8/13 not authenticated by APNP until 1/29/13 and 2/3/13; verbal order for Narcon medication dated 1/8/13 not authenticated by physician until 1/29/13, physician verbal orders for Pt #1's chest tube management dated 1/8/13 not authenticated by physician until 1/31/13.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am reveals the following: Thoracotomy post operative admission verbal orders dated 1/3/13 not authenticated by physician until 1/11/13.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following: physician verbal order confirming Pt #4's Discharge Medication Reconciliation dated 1/9/13 is not authenticated by physician until 1/21/13.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following: telemetry orders dated 1/8/13 not authenticated by physician until 1/21/13, and there is no documentation of signature, time, and date of authorized individual who received and recorded the telemetry order. Pt #5's Post-Operative Cardiovascular Surgery order set dated 1/8/13 is not authenticated by physician until 1/21/13.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM reveals the following: Pt #6's PRN (as needed) medication verbal orders dated 1/24/13 not authenticated by APNP until 1/30/13; telemetry verbal orders dated 1/24/13 not authenticated by APNP until 1/30/13.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following: Pt #7's Catheter Ablation pre-procedure admission verbal orders dated 1/29/13 not authenticated by physician until 2/12/13; Catheter Ablation post-procedure verbal orders dated 1/29/13 not authenticated by physician until 2/12/13.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following: Pt #8's telemetry verbal orders dated 2/12/13 not authenticated by physician until 2/19/13; Standard PRN Medication verbal orders dated 2/12/13 not authenticated by physician until 2/19/12; Intraoperative Medical Orders dated 2/12/13 not authenticated by physician until 2/19/13.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM reveals the following: Pt #9's telemetry verbal orders dated 2/21/13 not authenticated by physician until 3/6/13, Catheter Ablation post-procedure admission verbal orders dated 2/21/13 not authenticated by physician until 3/6/13.

Review of Pt #10's MR on 3/7/13 beginning at 1:36 PM reveals the following: Pt #10's Catheter Ablation pre-procedure admission verbal orders dated 2/22/13 not authenticated by physician until 3/6/13. Catheter Ablation post-procedure verbal orders dated 2/22/13 not authenticated by physician until 3/6/13.

The above findings were confirmed at the time of MR review with QM B and DIM C.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0461
Based on medical record review and staff interview the facility failed to ensure all History and Physicals completed within 30 days before admission are updated prior to surgical procedures in 10 of 10 MR's reviewed. This can potentially effect all patients receiving treatment at this facility.


Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM, revealed Pt #1's admission for a surgical procedure performed on 1/7/13. H&P completed by physician on 12/20/12. No update of H&P in MR prior to surgery.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am, revealed Pt #2's admission for a surgical procedure performed on 1/3/13. H&P completed by physician on 12/28/12. No update of H&P in MR prior to surgery.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM, revealed Pt #3's admission for a surgical procedure performed on 1/6/13. H&P completed by physician on 1/4/13. No update of H&P in MR prior to surgery.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am, revealed Pt #4's admission for a surgical procedure performed on 1/8/13. H&P completed by physician on 1/3/13. No update of H&P in MR prior to surgery.

Review of Pt #5's MR on 3/7/13 beginning at 11:30 am, revealed Pt #5's admission for a surgical procedure performed on 1/8/13. H&P completed by physician on 1/4/13. No update of H&P in MR prior to surgery.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM, revealed Pt #6's admission for a surgical procedure performed on 1/24/13. H&P completed by physician on 12/21/12. No update of H&P in MR prior to surgery.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM, revealed Pt #7's admission for a surgical procedure performed on 2/5/13. H&P completed by physician on 2/1/13. No update of H&P in MR prior to surgery.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM, revealed Pt #8's admission for a surgical procedure performed on 2/12/13. H&P completed by physician on 1/22/13. No update of H&P in MR prior to surgery.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM, revealed Pt #9's admission for a surgical procedure performed on 2/21/13. H&P completed by physician on 1/23/13. No update of H&P in MR prior to surgery.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM, revealed Pt #10's admission for a surgical procedure performed on 2/22/13. H&P completed by physician on 1/23/13. No update of H&P in MR prior to surgery.

Per interview with QM B on 3/7/13 beginning at 1:00 PM, physicians should be documenting an updated H&P prior to surgery.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, policy and procedure review, and staff interview the facility failed to ensure all MR's contain pertinent information to monitor and assess each patient's condition in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially affect all patient's receiving treatment at this facility.

Review on 3/7/13 of Policy--TWHH Patient Care Guidelines--Inpatient Department, last updated 9/2012 revealed the following:
-All physical assessments will be done on critical care patients every 4 hours or as needed and documented in the electronic health record.
-vital signs include blood pressure, pulse, respiratory rate, temperature and pulse oximetry.
-ICU patients should have vitals signs done every hour or more frequently if patient is unstable.
-Post-anesthesia recovery patients will have vital signs done every 15 minutes.
-The Aldrete score will be done by the RN on admission to unit post-general anesthesia or moderate sedation. The Aldrete score will be monitored every 15 minutes for a minimum of one hour and continue until they have reached an Aldrete score of greater than or equal to 8. If the patient is going to be classified as ICU status, the Aldrete score will need to be done every 15 minutes for one hour post-anesthesia or sedation and then the nurse will document "discharged to ICU status".

Review on 3/7/13 of Policy--Medical Record Documentation last revised 6/2011 revealed the following under "Record Content":
-The medical record will contain sufficient data needed to communicate pertinent information to other care providers and contain at least but not limited to the following information: Patient history and assessment findings as appropriate for condition, operative reports, progress notes, reassessment findings, response to therapies.

Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM, reveals the following: on 1/7/13 Pt #1 had a surgical procedure requiring general anesthesia. Pt #1's anesthesia stop time is 4:15 PM. Per Pt #1's physician orders dated 1/7/13 at 4:29 PM, Pt #1 is to have post surgical vital signs performed every 15 minutes until stable, then every 30 minutes for 6 hours. Pt #1's VS taken at 4:30 PM, 4:45 PM, 5:00 PM, 5:15 PM, 5:30 PM, 6:15 PM, 7:15 PM, 7:30 PM, 8:30 PM, 9:30 PM, and 10:30 PM do not include temperature. Per Pt #1's VS flowsheet, after the completion of Pt #1's 15 minutes VS's, Pt #1's VS's were only checked every hour and not every 30 minutes for 6 hours, as instructed in physician orders.

On 1/7/13 at 5:30 PM, documentation shows Pt #1 "remains ICU", per Pt #1's Post Anesthesia Recovery Orders dated 1/7/13, "discharge criteria" (from post anesthesia care) lists the following (including but not limited to): Aldrete score of 8, oriented to person, obeys simple commands, moves all extremities as per pre-procedure status, temperature of 36-37.8 Celsius. Review of Pt #1's MR reveals no documentation of Pt #1 meeting discharge criteria prior to placing patient in ICU status. COA D confirmed discharge criteria on Post Anesthesia Care Orders form.

Pt #1's comprehensive RN assessment documented on 1/7/13 at 4:15 PM reveals Pt #1's respiratory pattern is "irregular, shallow, tachypneic". No assessment documented identifying if Pt #1 is oriented to self. Documentation of a respiratory and neurological re-evaluation of abnormal findings not done until 8:30 PM; 4 hours and 15 minutes later.

Comprehensive RN assessment documented at 8:30 PM reveals the following documentation under Neurological assessment Glascow Coma scale(showing no improvement); eye opening "none", verbal response "none", and motor response "abnormal flex". Category under movement/sensation is documented "WDL (within defined limits)", the documentation of "WDL" is inconsistent with previous abnormal findings in regards to Pt #1's motor function.. Per Pt #1's RN assessment at 8:30 PM, no documentation noting a re-evaluation for the following issues; motor strength to assess weakness in all extremities, pupil reaction, and respiratory pattern. RN assessment re-evaluating abnormal findings including Pt #1's level of consciousness is not documented until 1/8/13 at 1:20 am; 4 hours and 45 minutes later. At 1:20 am the Glascow Coma scale showed no improvement, and the documentation listed the following; eye opening "none", verbal response "none", motor response "withdraws/pain".

Pt #1's Anesthesia Pre-Operative assessment dated [DATE] at 6:51 am shows no documentation of vital signs, boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications". Post Anesthesia Assessment reveals "intubated" or "extubated" box is not checked, nausea/vomiting and post operative pain assessments are blank. Anesthesia Intraoperative Report reveals "height" and "weight" documentation lines are blank.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 PM, reveals the following: Pt #2's Anesthesia Pre-Operative assessment dated [DATE] at 8:55 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, or pulse oximetry. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications". Pre-anesthesia assessment physical exam boxes labeled "heart", "lung" and "Dentition" are not checked off. Post-anesthesia assessment dated [DATE] at 1:15 PM reveals boxes labeled "RA (room air)" and "O2" are blank. Pt #2's vital signs flow sheet dated 1/3/13 at 1:15 PM, 1:30 PM, 1:45 PM, 2:00 PM do not include temperature. No documentation in MR of when Pt #2 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following; Pt #3's Anesthesia Pre-Operative assessment dated [DATE] at 6:40 am shows only documentation of BP, Pulse, and pulse oximetry; no documentation of respiratory rate and temperature. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications." Post-anesthesia assessment form dated 1/6/13 at 12:34 PM shows the following: "neuro status", "nausea/vomiting", and "post-op pain assessment" boxes are not checked. Intra operative anesthesia record dated 1/6/13 show the "estimated blood loss" line is blank. Documentation of Pt #3's VS's in the MR do not consistently include temperature and respiratory rate. No documentation in MR of when Pt #3 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following; Pt #4's Anesthesia Pre-Operative assessment dated [DATE] at 2:00 PM shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Post-anesthesia assessment dated [DATE] at 5:15 PM reveals boxes labeled "RA (room air)" and "O2" are blank. Intra operative anesthesia record dated 1/8/13 show the "estimated blood loss" category is blank, "IV fluids 0.9 NS" is checked, no documentation of amount of IV fluids administered to Pt #4. Pt #4's post surgical VS's do not consistently document temperature, pulse, and respirator rate. Per Pt #4's MR, there is only documentation of 1 Aldrete score assessment post surgery. No documentation in MR of when Pt #4 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following; Pt #5's Pre-Operative Anesthesia assessment dated [DATE] at 7:00 am shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Per Pt #5's Pre-anesthesia assessment form, "Allergies" and "Meds" categories are blank. Post-anesthesia assessment dated [DATE] at 2:00 PM reveals boxes labeled "RA (room air)" and "O2" are blank. Intra operative anesthesia record dated 1/8/13 reveals the following; "estimated blood loss" category is blank, "IV fluids 0.9 NS" is checked, no documentation of amount of IV fluids administered to Pt #5. Per Pt #5's MR, documentation of VS's does not consistently include temperature.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM reveals the following; no evidence of documenting Pt #6's Operative Report; pre-operative anesthesia assessment dated [DATE] at 10:00 am shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Per Pt #6's MR, VS's do not consistently include temperature, respiratory rate, and BP. Pt #6's Aldrete score post surgery shows documentation every 15 minutes for only 45 minutes. No documentation in MR of when Pt #6 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following; Pt #7's Anesthesia Pre-Operative assessment dated [DATE] at 8:35 am shows no documentation of Pt #6's VS's. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications". Pt #7's post anesthesia assessment form dated 2/5/13 at 1:16 PM reveals "Temp" category is blank. Pt #7's intraoperative anesthesia form dated 2/5/13 shows "Total Urine Output" category is blank; "Surgeon" category is blank. No documentation in MR of when Pt #7 was discharged from post anesthesia recovery care as per policy. Per Pt #7's MR, VS's do not consistently include temperature, pulse, and respiratory rate. Per patient orders dated 2/5/13 at 8:30 am, post surgical VS's are as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #7's MR reveals VS taken every 15 minutes from 1:30 PM until 3:45 PM, and then all VS's not documented again until 7:45 PM; 3 hours 30 minutes later.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following; Pt #8's Pre-Operative Anesthesia assessment dated [DATE] at 5:40 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Pt #8's Post operative anesthesia assessment dated [DATE] at 11:45 am reveals the following; "O2 sat (saturation)" category is blank; boxes labeled "RA (room air)" and "O2" are blank; "Temp" category is blank; "Neuro status" assessment boxes are not checked; "Nausea/vomiting" assessment boxes are blank; "post op pain assessment" boxes are not checked. Per Pt #8's MR, VS's do not consistently include temperature and respiratory rate. Pt #8's Aldrete score post surgery shows documentation every 15 minutes for only 30 minutes. No documentation in MR of when Pt #8 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM reveals the following; Pt #9's Pre-Operative Anesthesia assessment dated [DATE] at 6:30 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Per Pt #9's MR, VS's do not consistently include temperature and respiratory rate. Per patient orders dated 2/21/13 at 8:00 am, post surgical VS's are as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #9's MR reveals VS's documented every 15 minutes from 11:15 am to 2:00 PM and then not until 4:30 PM; 2 hours and 30 minutes later. Pt #9's Aldrete score post surgery shows documentation every 15 minutes for only 45 minutes. No documentation in MR of when Pt #9 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following; Pt #10's Pre-Operative Anesthesia assessment dated [DATE] at 9:06 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Pt #10's intraoperative anesthesia report dated 2/22/13 reveals the following; "IV fluids" category displays a check mark next to "LR" (Lactated Ringer) and "0.9 NS"(normal saline) no documentation of amount of IV fluids administered to Pt #10; "Estimated Blood Loss" line is blank. Per patient orders dated 2/22/13 at 8:30 am, post surgical VS's are as follows; every 15 minutes x 4, every 30 minutes x 4, then every hour x 4; then routine. Review of Pt #10's MR reveals VS's documented every 15 minutes from 2:25 PM to 4:00 PM and then not until 6:29 PM; 2 hours and 29 minutes later. Per Pt #10's MR, VS's documented do not consistently include temperature and respiratory rate. Pt #10's Aldrete score post surgery shows documentation every 15 minutes for only 45 minutes. No documentation in MR of when Pt #10 was discharged from post anesthesia recovery care and changed to ICU (Intensive Care Unit) status as per policy.

The above findings were confimed at the time of MR review with QA B and DIM C.
VIOLATION: HISTORY AND PHYSICAL Tag No: A0952
Based on medical record review and staff interview the facility failed to ensure all History and Physicals completed within 30 days before admission are updated prior to surgical procedures in 10 of 10 MR's reviewed(Pt #1,2,3,4,5,6,7,8,9,10). This can potentially affect all patients receiving treatment at this facility.


Findings include:

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM, revealed Pt #1's admission for a surgical procedure performed on 1/7/13. H&P completed by physician on 12/20/12. No update of H&P in MR prior to surgery.

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am, revealed Pt #2's admission for a surgical procedure performed on 1/3/13. H&P completed by physician on 12/28/12. No update of H&P in MR prior to surgery.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM, revealed Pt #3's admission for a surgical procedure performed on 1/6/13. H&P completed by physician on 1/4/13. No update of H&P in MR prior to surgery.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am, revealed Pt #4's admission for a surgical procedure performed on 1/8/13. H&P completed by physician on 1/3/13. No update of H&P in MR prior to surgery.

Review of Pt #5's MR on 3/7/13 beginning at 11:30 am, revealed Pt #5's admission for a surgical procedure performed on 1/8/13. H&P completed by physician on 1/4/13. No update of H&P in MR prior to surgery.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM, revealed Pt #6's admission for a surgical procedure performed on 1/24/13. H&P completed by physician on 12/21/12. No update of H&P in MR prior to surgery.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM, revealed Pt #7's admission for a surgical procedure performed on 2/5/13. H&P completed by physician on 2/1/13. No update of H&P in MR prior to surgery.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM, revealed Pt #8's admission for a surgical procedure performed on 2/12/13. H&P completed by physician on 1/22/13. No update of H&P in MR prior to surgery.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM, revealed Pt #9's admission for a surgical procedure performed on 2/21/13. H&P completed by physician on 1/23/13. No update of H&P in MR prior to surgery.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM, revealed Pt #10's admission for a surgical procedure performed on 2/22/13. H&P completed by physician on 1/23/13. No update of H&P in MR prior to surgery.

Per interview with QM B on 3/7/13 beginning at 1:00 PM, physicians should be documenting an updated H&P prior to surgery.
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
Based on staff interview, medical record review, and manufacturers guidelines the facility failed to develop surgical policies and procedures reducing risk of surgical fires, and document alcohol based skin prep is dry prior to draping in 3 of 3 interviews(SM H, SO I, DIR A) 4 of 10 MR ' s reviewed (Pt 1,2,3,5). This can potentially affect all patient's receiving surgery at this facility.

Per review on 3/7/13 of Duraprep Surgical Solution Drug Facts (Manufacturers guidelines)--to reduce the risk of fire, wait until solution is completely dry--minimum of 3 minutes on hairless skin; up to 1 hour in hair.

Per review on 3/7/13 of Chloraprep manufacturers guidelines in package--solution contains alcohol and gives off flammable vapors, do not drape or use ignition source until solution is completely dry--minimum of 3 minutes on hairless skin; up to 1 hour in hair.

Findings include:

Per interview on 3/6/13 beginning at 1:00 PM with SM H (surgery manager), staff use Duraprep or Chloraprep routinely to prepare and disinfect skin prior to surgery; per manufacturers package inserts both solutions contain at least 70% alcohol. Per SM H staff do not document if alcohol skin prep solution is completely dry and area is inspected prior to draping. Per SM H the facility does not have a policy and procedure guiding the use of alcohol skin preps and risks of patient catching on fire in the operating room. Per interview SM H was unsure how long Chloraprep takes to dry.

Per interview with Dir A on 3/6/13 beginning at 2:11 PM, facility follows AORN (Association of PeriOperative Registered Nurses) Guidelines for "patient on fire" in the operating room, however the facility does not maintain written policies and procedures developed by the facility consistent with the facilities needs and resources to minimize the risk of surgical fires.

Review of MR's on 3/6/13 and 3/7/13 revealed the following; Pt #1,2,3 and 5 used Duraprep solution for skin prep prior to surgery, no documentation that alcohol based skin prep solution was dry prior to draping.

Per interview with RN J on 3/7/13 beginning at 10:00 am, cardiovascular technicians(CVT) prep the skin with Chlorahexidine solution for procedures performed in the cardiac catheterization lab; Per RN J CVT's do not document skin prep solution drying time. Per RN J the facility does not have a policy and/or procedure governing the CVT's duties and responsibilities in the cath lab including but not limited to; CVT protocol for all surgical procedures in the cath lab(i.e.. equipment, materials, supplies needed) and sterilization and disinfection procedures. RN J only able to provide surveyor with a CVT competency check list.

Per interview on 3/7/13 beginning at 11:24 am with SO I (safety officer), the facility does not perform drills to prepare staff on what to do if a patient catches on fire in the operating room.
VIOLATION: POST-OPERATIVE CARE Tag No: A0957
Based on 2 of 2 staff interviews (DIR A, COA D) the facility failed to have policies and procedures governing post anesthesia care of patients going directly from surgery to an inpatient bed. This can potentially affect all patients receiving surgery at this facility.


Findings include:

Per interview with DIR A on 3/6/13 beginning at 2:10 PM, facility has an "acuity adaptable model" and does not have a separate Post Anesthesia Care Unit. After surgery patients are transferred directly to an inpatient bed and all RN's are trained as ICU "intensive care unit" nurses. Per DIR A the facility follows ASA (American Society of Anesthesiologists) and AORN (Association of periOperative Registered Nurses) guidelines, but do not have a facility policy and procedure governing immediate post operative monitoring specific to the unique needs and resources of the facility (i.e. acuity adaptable model).

Review of 10 surgical MR's (Pt #1,2,3,4,5,6,7,8,9,10), on 3/6/13 and 3/7/13 reveals RN documentation of when the patient is transferred out of post anesthesia recovery and considered in ICU status is inconsistent. There is no documentation of a post anesthesia discharge assessment of patients to ensure discharge criteria is met prior to reducing the level of monitoring.

Per interview with COA D on 3/7/13 beginning at 8:50 am, in reference to the acuity adaptable model and post anesthesia care, COA D stated there should be something in place that clearly defines the difference of phase 1 and phase 2 post anesthesia care.
VIOLATION: PRE-ANESTHESIA EVALUATION Tag No: A1002
Based on 2 of 2 staff interviews (DIR A, COA D) and review of policy and procedures the facility failed to have a comprehensive policy and procedure for anesthesia services. This can potentially affect all patients receiving surgery at this facility.

Findings include:

Per interview with DIR A on 3/6/13 beginning at 2:00 PM, the facility follows the standards of practice for ASA (American Society of Anesthesiologists). Per DIR A the facility does not have a facility specific policy and procedure addressing the documentation requirements of pre and post anesthesia assessments.

Review on 3/7/13 of policy--Provision of Anesthesia Services, last reviewed 1/2013 reveals policy does not address specific issues related to the facility's "acuity adaptable model" and the management of patients going directly from surgery to an inpatient bed. The policy does not address issues including but not limited to: infection control measures, safety practices in all anesthetizing areas, protocol for supportive life functions i.e. cardiac and respiratory emergencies; reporting requirements, documentation requirements, equipment requirements as well as the monitoring , inspection, testing, and maintenance of anesthesia equipment in the hospital biomedical equipment program, and the delineation of pre- and postanesthesia staff responsibilities.

Per interview with COA D on 3/7/13 beginning at 8:50 am, confirmed there is no policy and procedure addressing pre and post anesthesia assessments, and also confirmed pre and post anesthesia requirements are not listed in the medical staff by laws.
VIOLATION: ANESTHESIA RECORD Tag No: A1003
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, medical record review, and ASA "Statement on Documentation of Anesthesia Care" the facility failed to ensure pre-anesthesia evaluation include all the required components in 10 of 10 MR's reviewed (Pt #1,2,3,4,5,6,7,8,9,10). This can potentially affect all patients receiving surgery at this facility.

Findings include:

Per interview with DIR A on 3/6/13, the facility follows the ASA (American Society of Anesthesiologists) guidelines for documentation requirements of pre, intra, and post anesthesia evaluations. When asked for documentation of what the facility follows, surveyor given the, "Statement on Documentation of Anesthesia Care" approved by the ASA house of delegates on 10/22/2008. Per the ASA document the pre anesthesia physical exam shall include vitals signs.

Pt #1's Anesthesia Pre-Operative assessment dated [DATE] at 6:51 am shows no documentation of vital signs, boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications".

Review of Pt #2's MR on 3/6/13 beginning at 11:08 am, reveals the following: Pt #2's Anesthesia Pre-Operative assessment dated [DATE] at 8:55 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, or pulse oximetry. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications". Pre-anesthesia assessment physical exam boxes labeled "heart", "lung" and "Dentition" are not checked off.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following; Pt #3's Anesthesia Pre-Operative assessment dated [DATE] at 6:40 am shows only documentation of BP, Pulse, and pulse oximetry; no documentation of respiratory rate and temperature. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications".

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following; Pt #4's Anesthesia Pre-Operative assessment dated [DATE] at 2:00 PM shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following; Pt #5's Pre-Operative Anesthesia assessment dated [DATE] at 7:00 am shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry. Per Pt #5's Pre-anesthesia assessment form, "Allergies" and "Meds" categories are blank.

Review of Pt #6's MR on 3/7/13 beginning at 12:15 PM reveals the following; Pt #6's Pre-operative anesthesia assessment dated [DATE] at 10:00 am shows only documentation of BP, Pulse; no documentation of respiratory rate, temperature, and pulse oximetry.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following; Pt #7's Anesthesia Pre-Operative assessment dated [DATE] at 8:35 am shows no documentation of Pt #6's VS's. Boxes labeled "y" and "n" not checked documenting if there is "previous anesthetic experience; Hx anesthetic complications".

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following; Pt #8's Pre-Operative Anesthesia assessment dated [DATE] at 5:40 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry.

Review of Pt #9's MR on 3/7/13 beginning at 1:15 PM reveals the following; Pt #9's Pre-Operative Anesthesia assessment dated [DATE] at 6:30 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following; Pt #10's Pre-Operative Anesthesia assessment dated [DATE] at 9:06 am shows only documentation of BP and Pulse; no documentation of respiratory rate, temperature, and pulse oximetry.

The above findings were confirmed at the time of MR review with QA B and DIM C.
VIOLATION: INPATIENT POST-ANESTHESIA EVALUATION Tag No: A1004
Based on staff interview, medical record review, and ASA "Statement on Documentation of Anesthesia Care" the facility failed to ensure the intraoperative anesthesia record includes all required components in 4 of 10 MR's reviewed (Pt #3,4,5,10). This can potentially affect all patients receiving surgery at this facility.

Findings include:

Per interview with DIR A on 3/6/13 at 2:00 pm, the facility follows the ASA (American Society of Anesthesiologists) guidelines for documentation requirements of pre, intra, and post anesthesia evaluations. When asked for documentation of what the facility follows, surveyor given the, "Statement on Documentation of Anesthesia Care" approved by the ASA house of delegates on 10/22/2008.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following; Pt #3's Intra operative anesthesia record dated 1/6/13 shows the "estimated blood loss" line is blank.

Review of Pt #4's MR on 3/7/13 beginning at 9:40 am reveals the following; Pt #4's Intraoperative anesthesia record dated 1/8/13 shows the "estimated blood loss" category is blank, IV fluids "0.9 NS" is checked, no documentation of amount of IV fluids administered to Pt #4.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following; Pt #5's Intraoperative anesthesia record dated 1/8/13 reveals the following; "estimated blood loss" line is blank, IV fluids "0.9 NS" is checked, no documentation of amount of IV fluids administered to Pt #5.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following; Pt #10's intraoperative anesthesia report dated 2/22/13 reveals the following; "IV fluids" category displays a check mark next to "LR" (Lactated Ringer) and "0.9 NS"(normal saline) no documentation of amount of IV fluids administered to Pt #10; "Estimated Blood Loss" line is blank.

The above findings were confimed at the time of MR review with QA B and DIM C.
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, medical record review, and ASA "Statement on Documentation of Anesthesia Care" the facility failed to ensure the post anesthesia evaluations include all required components and allow for patient participation in the evaluation in 6 of 10 MR's reviewed (Pt #1,3,5,7,8,10). This can potentially affect all patients receiving surgery at this facility.

Findings include:

Per interview with DIR A on 3/6/13 at 2:00 pm, the facility follows the ASA (American Society of Anesthesiologists) guidelines for documentation requirements of pre, intra, and post anesthesia evaluations. When asked for documentation of what the facility follows, surveyor given the, "Statement on Documentation of Anesthesia Care" approved by the ASA house of delegates on 10/22/2008. Per review of ASA guidelines the following requirements were missing: pain and nausea/vomiting assessment.

Review of Pt #1's MR on 3/6/13 beginning at 3:50 PM, reveals the following: Pt #1's Post anesthesia shows no documentation of nausea/vomiting and pain assessments. According to Pt #1's intraoperative report, anesthesia end time was 4:15 PM; post anesthesia assessment documented at 4:17 PM, 2 minutes after anesthesia ended. Pt #1's neuro status is documented as "altered" and "sedated"; this condition does not allow for Pt #1 to participate in the post anesthesia evaluation.

Review of Pt #3's MR on 3/6/13 beginning at 3:20 PM reveals the following; Pt #3's Post-anesthesia assessment form dated 1/6/13 at 12:34 PM shows no documentation of level of consciousness, nausea/vomiting, and pain assessment. According to Pt #3's intraoperative report, anesthesia end time was 12:27 PM; post anesthesia assessment documented at 12:34 PM. Pt #3's mental status is documented as "sedated", "intubated" box is marked; this condition does not allow for Pt #3 to participate in the post anesthesia evaluation.

Review of Pt #5's MR on 3/7/13 beginning at 11:35 am reveals the following; according to Pt #3's intraoperative report, anesthesia end time was 3:30 PM; post anesthesia assessment documented at 2:00 PM; 1 hour and 30 minutes before anesthesia ended. Pt #5's mental status is documented as "sedated", "intubated" box is marked; this condition does not allow for Pt #5 to participate in the post anesthesia evaluation.

Review of Pt #7's MR on 3/7/13 beginning at 12:30 PM reveals the following; Pt #7's post anesthesia assessment form dated 2/5/13 at 1:16 PM shows no documentation of temperature vital sign.

Review of Pt #8's MR on 3/7/13 beginning at 1:00 PM reveals the following; Pt #8's Post operative anesthesia assessment dated [DATE] at 11:45 am reveals the following; no documentation of temperature vital sign, nausea/vomiting, and pain assessment. Pt #8's mental status is documented as "sedated" and "intubated" box is marked; this condition does not allow for Pt #8 to participate in the post anesthesia evaluation.

Review of Pt #10's MR on 3/7/13 beginning at 1:35 PM reveals the following; According to Pt #10's intraoperative report, anesthesia end time was 2:40 PM; post anesthesia assessment documented at 2:00 PM, 40 minutes before anesthesia ended.

The above findings were confirmed at the time of MR review with QA B and DIM C.