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ASCENSION SE WISCONSIN HOSPITAL - ST JOSEPH CAMPUS 5000 W CHAMBERS ST MILWAUKEE, WI 53210 Sept. 30, 2014
VIOLATION: OUTPATIENT POST-ANESTHESIA EVALUATION Tag No: A1005
Based on record review the facility failed to ensure the L & D (labor and deliver) anesthesia record includes documentation of a post anesthesia evaluation for 3 of 6 patients receiving an epidural (regional anesthesia) during labor, in a sample of 10 MR reviewed.

Findings Include:

Review on 9/30/14 beginning at 2:00 PM of P & P titled, " Provision of Anesthesia Services" last revised 4/2013 states, a post-anesthesia evaluation must be completed and documented no later then 48 hours after surgery or a procedure requiring anesthesia services. The evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia.

Review on 9/30/14 beginning at 2:00 PM of L & D "Anesthesia Record" for Pt 3, 4, and 5 shows patients received an epidural during labor; Pt 3, 4, and 5's "Anesthesia Record" shows the section titled, "Post Anesthesia Evaluation" is blank.
VIOLATION: INPATIENT POST-ANESTHESIA EVALUATION Tag No: A1004
Based on record review and interview the facility failed to ensure the L & D (labor and deliver) anesthesia record includes documentation for 2 of 6 patients receiving an epidural (regional anesthesia) during labor, in a sample of 10 MR reviewed.

Findings Include:

Review on 9/30/14 beginning at 2:00 PM of P & P titled, " Provision of Anesthesia Services" last revised 4/2013 states, Patients shall be monitored during the administration of anesthesia, the documentation shall address including but not limited to; the name, dosage, route and time of administration of drugs and anesthesia agents, techniques used and patient position, name and amounts of IV fluids.

Review on 9/30/14 beginning at 2:00 PM of L & D "Anesthesia Record" form for Pt 1 and 5 revealed the following:

Per Pt #1's Anesthesia Record dated 4/7/14, Pt #1's epidural infusion was started at 7:30 am via IV pump at 8 cc per hour. Per Pt #1 Obstetrical Assessment Record dated 4/7/14, in addition to the epidural infusion, Pt #1 self administered an epidural bolus via PCA pump (patient-controlled anesthesia) at 9:45 am, 10:15 am, 10:45 am, 11:15 am, 11:45 am, 12:15 PM, and 1:15 PM. Review of Pt #1's Anesthesia Record show no documentation of an epidural bolus dose.

Per Pt #5's Anesthesia Record dated 5/11/14, Pt #5's epidural infusion was started at 3:30 PM via IV pump at 7 cc per hour. Per Pt #1 Obstetrical Assessment Record dated 5/11/14, in addition to the epidural infusion, Pt #5 self administered an epidural bolus via PCA pump (patient-controlled anesthesia) at 7:20 PM and 8:10 PM. Review of Pt #5's Anesthesia Record shows no documentation of an epidural bolus dose.

Per interview on 9/30/14 beginning at 2:00 PM with QA B, RN D, and RN E some patients are prescribed an epidural bolus via PCA pump in addition to epidural infusion during labor, however there is no documentation of the epidural bolus dose in the above medical records reviewed. Further interview with RN D and RN E revealed that anesthesia staff programs, controls, and monitors the epidural IV pumps while patients are in labor.