HospitalInspections.org

Based on interview and record review the hospital failed to ensure changes in 1 of 5 patients reviewed, [Patient #1's] medical condition [left eye redness and pain] were documented on the discharge paperwork for follow-up care.

Findings Included:

1)The operative report dated 05/6/10 reflected, Patient #1 was "admitted to the Hospital on 05/5/10 for outpatient procedure, painful abdominal wall scarring, nevi of the upper lip, nose and left cheek, lipectomy of abdomen and hip, and full thickness excision of upper lip, left naris, nasal tip and two left cheek lesions, all less than 0.6 cm in diameter ...the patient was awakened from anesthesia, extubated, and taken to recovery in good condition ..."
The interdisciplinary notes dated 05/5/10 timed at 2100 reflected, "complained left eye red and burning sensation warm moisture washcloth applied ...up to bathroom voided ...2110 notified Dr. ... about patient's left eye condition with redness noted and burning sensation, but vision intact ...order received ...at 2140 discharge instructions given and voiced understanding ..."

The physician's orders dated 05/5/10 timed at 2110 reflected, "eye patch to left eye ...if burning sensation not improving ...eye vision changes please contact your surgeon ...ok to discharge home ..."

The surgical discharge instructions dated 05/5/10 timed at 2130 reflected, "wear binder three weeks, call Dr...in AM for follow-up visit schedule 05/11/10 [time ?], may wash face with soap and H20 [water] while shower, may change dressing on liposuction incision area including hip ...shower ok, no submerged H20 till wound completely healing ...empty JP [Jackson Pratt] drains and document ... " No further documentation was found on the document indicating Patient #1 had a problem with pain/redness to her left eye and what medical follow-up was to be provided.

On 07/22/10 at 2:45 PM RN #4 was interviewed. RN #4 stated she was the nurse who evaluated Patient #1's left eye complaint. RN #4 said the patient attempted to touch her eyes after surgery but she told her not to. RN #4 stated Patient #1 complained of burning and some pain in the left eye. She stated she looked at Patient #1's left eye and it was a little red. RN #4 stated she evaluated the patient ' s vision and the patient was able to see. RN #4 stated she called the Anesthesia physician and he ordered an eye patch, and for the patient to contact her surgeon if any further problems. RN #4 stated she forgot to address the patient's red and painful eye in the discharge paperwork. It should be noted the patient's surgeon was unaware of the patient's red and painful eye upon discharge.

On 07/23/10 at 12:00 noon Physician #5 was interviewed by phone. Physician #5 stated the nurse called him regarding Patient #1's left eye. He stated he gave discharge orders and to cover the eye with an eye patch and for the patient to follow-up with her surgeon. Physician #5 stated he did not communicate with Patient #1's surgeon about the patient's red and painful eye.

On 07/23/10 at 12:30 PM RN #1 was interviewed. RN #1 was asked to review the discharge paperwork dated 05/5/10. RN #1 stated Patient #1's left eye redness should have been addressed on the paperwork.

The policy entitled, "Discharge from PACU" with a revision date of 02/9/10 reflected, the purpose is "to assure the patient's transfer from PACU to post-operative area will be smooth as possible and continuity of care is maintained..."