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The Condition of Participation for Quality Assessment and Performance Improvement Program was not met. Based on record review, observations and interviews the Hospital failed to review their internal incident report to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement.

Findings include:

Based on records reviewed, observations and interview for one (Patient #3) of 12 sampled patients, the Hospital failed to identify opportunities for improvement, implement changes that will lead to improvement, and thoroughly review an incident involving a Certified Registered Nurse Anesthetist (CRNA) who failed to appropriately monitor Patient #3 following administration of pre-operative medications resulting in Patient #3 experiencing apnea (cessation of breathing), pulselessness requiring cardiopulmonary resuscitation (CPR) and neurological brain damage.


Refer to TAG: A-0283

Based on records reviewed, observations and interview for one (Patient #3) of 12 sampled patients, the Hospital failed to identify opportunities for improvement, implement changes that will lead to improvement, and thoroughly review an incident involving a Certified Registered Nurse Anesthetist (CRNA) who failed to appropriately monitor Patient #3 following administration of pre-operative medications resulting in Patient #3 experiencing apnea (cessation of breathing), pulselessness while not on a monitor requiring cardiopulmonary resuscitation (CPR) and neurological brain damage.

Findings include:

The document titled Surgery Procedure Event 15112 dated 9/5/18, indicated that Patient #3 had multiple co-morbidities including severe anemia, sleep apnea and a traumatic brain injury and was scheduled for an orthopedic procedure. The document indicated that Patient #3 received 50 Micrograms (mcgs) of Fentanyl (narcotic) which appeared to have caused a cardiopulmonary arrest. The document indicated that Patient #3 was resuscitated and there was a return of spontaneous circulation; however, return to baseline neurological function was not recovered. The document indicated that the precise course of events was somewhat unclear and Patient #3 may have been in asystole (no heartbeat) for a prolonged period of time (up to 30 minutes). Under the section Resolutions and Outcomes, the document indicated that the severity level of the event was documented as severe/permanent harm.

The document titled Serious Adverse Event 15112 dated 9/5/18, indicated that Patient #3 was pre-medicated with Versed (sedating medication) 1 Milligram (mg), at 11:15 A.M. in the Surgical Day Care area and was then brought into the Operating Room (OR) suite, at 11:16 A.M. There no indication that Patient #3's vital signs (heart rate, blood pressure, and oxygen saturation) were measured after the Versed was administered. Upon arrival into the OR, the Certified Registered Nurse Anesthetist #1 (CRNA) gave Patient #3 two doses of Fentanyl 50 mcg at 11:25 A.M. and 11:28 A.M. The document indicated that Patient #3 ceased respirations and no pulses could be felt and a code was called at 11:29 A.M.

Review of the American Society of Anesthesiologist (ASA) Guidelines (Anesthesiology 2002: 96:1004-17) indicate that (pulse) oximetry (measures oxygen in blood) effectively detects oxygen desaturation and hypoxemia (low oxygen levels) in patients who are administered sedatives/analgesics. All patients undergoing sedation/analgesia should be monitored by pulse oximetry with appropriate alarms if available.

The intraoperative document titled (Hospital name removed) Anesthesia dated 9/6/18, at 8:24 (A.M./P.M. not indicated) on 10/9/18, indicated that Patient #3 was assessed as an American Society of Anesthesiologists (ASA) Class 3 (a patient with severe systemic disease). The document indicated that Patient #3 received Versed 1 mg intravenously (IV) at 11:15 A.M. on 9/5/18. The document indicated that Patient #3 received Fentanyl 50 mcgs IV at 11:25 A.M. and 11:29 A.M. on 9/5/18. The document indicated that the first set of vital signs was recorded at 11:29 A.M. when the code was called (14 minutes after the Versed was administered and 4 minutes after the Fentanyl). The document indicated that the first oxygen saturation was measured as 87.4% (Normal Range is 95-100) at 11:35 A.M. (20 minutes after the Versed was administered and 10 minutes after the first dose of Fentanyl). There was no indication Patient #3's oxygen saturation was being monitored at the time the Fentanyl was administered.

The Surveyors interviewed the Attending Anesthesiologist on 10/9/18 at 10:52 A.M. The Attending Anesthesiologist said that he was assigned to Patient #3's care on 9/5/18 along with the CRNA. The Attending Anesthesiologist said that the CRNA was responsible for meeting Patient #3 in Pre-Op and transporting Patient #3 to the OR. The Attending Anesthesiologist said that the CRNA met Patient #3 in Pre-Op and pre-medicated him/her with Versed 1mg. The Attending Anesthesiologist said that the CRNA escorted Patient #1 to the OR with Circulating Nurse #1 and Patient #3 was not monitored. The Attending Anesthesiologist said patients are sometimes monitored if they had co-morbidities. The Attending Anesthesiologist said that, once Patient #3 was in the OR suite, the CRNA administered two doses of Fentanyl 50 mcg and noted that Patient #3 was apneic (not breathing). The Attending Anesthesiologist said that the CRNA called him for assistance. The Attending Anesthesiologist said that he was unable to assist because he was taking care of another patient so he asked another Anesthesiologist to assist the CRNA. The Attending Anesthesiologist said almost immediately after he hung up with the CRNA he heard a Code Blue called for Patient #3's OR suite. The Attending Anesthesiologist said that he attended a Debriefing 2-3 days after the event. The Attending Anesthesiologist said that the Chief of Anesthesia, the CRNA and Circulating Nurse #1 were in attendance and some others that he could not recall. The Attending Anesthesiologist said that they discussed several ideas such as monitoring pre-medicated patients who were being transported from Pre-Op to the OR with an oxygen saturation monitor, but this was not implemented as a practice change. The Attending Anesthesiologist said these were just discussed as a group and was not aware of any practice changes.

The Surveyors interviewed Perioperative Nurse #1 on 10/9/18, at 12:12 P.M. Perioperative Nurse #1 said that Patient #3 arrived at Pre-Op in a wheel chair with his/her Continuous Positive Airway Pressure (CPAP) equipment which is used for his/her obstructive sleep apnea. The Perioperative Nurse #1 said that Patient #3 was alert, awake and conversational. The Perioperative Nurse #1 said that Patient #3 denied pain or discomfort. Perioperative Nurse #1 said that Patient #3 arrived with a Peripherally Inserted Central Catheter (PICC) line in place. Perioperative Nurse #1 said that the PICC could not be accessed and that the Attending Anesthesiologist established a peripheral line. Perioperative Nurse #1 said that Patient #3 was transported to the OR with Circulating Nurse #1 and the CRNA. Perioperative Nurse #1 said that Patient #3 was not complaining of pain at the time of transport and she did not hear Patient #3 complain of pain while being transported to the OR. Perioperative Nurse #1 said that she attended a debriefing the next day with the OR staff. Perioperative Nurse #1 said that they discussed the case during the debriefing and after the debriefing there were no practice changes implemented.

The Surveyors interviewed Circulating Nurse #1 on 10/9/18, at 12:32 P.M. Circulating Nurse #1 said that she was assigned to Patient #3's surgical procedure on 9/5/18. Circulating Nurse #1 said that she met Patient #3 in the Pre-Op department and introduced herself and took report from Perioperative Nurse #1. Circulating Nurse #1 said the CRNA was also in Pre-Op while she received report. Circulating Nurse #1 said that Patient #3 appeared unkempt and thin but was alert, conversational and did not appear to be in any pain. Circulating Nurse #1 said that she did not recall when the CRNA administered Versed 1 mg but was aware that Patient #3 received Versed. Circulating Nurse #1 said that, shortly after receiving report, she and the CRNA transported Patient #3 to the OR. Circulating Nurse #1 said that during the transport from Pre-Op to the OR, Patient #3 was not alert and was mumbling and Circulating Nurse #1 assumed this was due to the Versed. Circulating Nurse #1 said that Patient #3 was not on a monitor, complaining of pain, or talking during the transport to the OR. Circulating Nurse #1 said that when Patient #3 arrived to the OR suite at 11:16 A.M., he/she was positioned next to the procedure table and prepared to be transferred to the procedure table. Circulating Nurse #1 said that Patient #3 was not talking at this time and did not complain of pain or discomfort. Circulating Nurse #1 said that Patient #3 was medicated with Fentanyl and was not on a monitor at this time. Circulating Nurse #1 said that herself, Surgical Tech #1, Surgical Tech #2, and the CRNA were in the room. Circulating Nurse #1 said that when they went to move Patient #3 to the procedure table it was discovered that Patient #3 was incontinent. Circulating Nurse #1 said that Patient #3 was rolled on his/her side to be cleaned and was not on the monitor and was not receiving oxygen. Circulating Nurse #1 said that, while cleaning Patient #3, the CRNA said "We have to move him/her". Circulating Nurse #1 said that at that time she noticed that Patient #3 was not breathing and said "I don't think he/she is breathing". Circulating Nurse #1 said that Patient #3 was then placed on the Blood Pressure, Cardiac, and Oxygen saturation monitors and was then administered oxygen for the first time. Circulating Nurse #1 said that she called the Attending Anesthesiologist with the CRNA's phone and told him that they needed help and the CRNA took the phone. Circulating Nurse #1 said that Circulating Nurse #2 came into the room during this time and asked "Is everything was ok?", Circulating Nurse #1 said "No" and Circulating Nurse #2 asked "Is there a pulse?" Circulating Nurse #1 said "No". Circulating Nurse #1 said that Circulating Nurse #2 pushed the Code button on the OR suite wall and then came back to the procedure table and started compressions. Circulating Nurse #1 said that the Anesthesia Charge physician arrived and intubated Patient #3 while the code proceeded and a pulse was eventually detected and Patient #3 was transferred to Cat Scan (Computed Tomography) and then to the Intensive Care Unit (ICU).

Circulating Nurse #1 said that, two days after this event, there was a debriefing with all staff involved. Circulating Nurse #1 said that at the debriefing she discussed that Patient #3 was not alert and was mumbling during transport and was not on a monitor and thought it would be a good idea to start monitoring pre-medicated patients during transport from Pre-Op. Circulating Nurse #1 said that there were no practice changes or new policy developed after the debriefing.

The Surveyors interviewed the Chief of Anesthesia on 10/10/18 at 9:47 A.M. The Chief of Anesthesia said that he first heard of the event from the Anesthesia Charge physician later in the day on 9/5/18. The Chief of Anesthesia said he was updated by the Anesthesia Charge physician and that several other staff members came to him and updated him on the event. The Chief of Anesthesia said that he did not interview the CRNA at this time because the CRNA had gone home for the day. The Chief of Anesthesia said that the CRNA had premedicated Patient #3 in the Pre-Op area because Patient #3 was anxious. The Chief of Anesthesia said that Circulating Nurse #1 and the CRNA transported Patient #3 to the OR and that Patient#3 was complaining of pain. The Chief of Anesthesia said that once inside the OR suite, the CRNA medicated Patient #3 with Fentanyl 50 mcg IV. The Chief of Anesthesia said that Patient #3 again complained of pain while in the OR and was again medicated with Fentanyl 50 mcg and became unresponsive. The Chief of Anesthesia said that Patient #3 was assisted with ventilation by the CRNA and a code was called. The Chief of Anesthesia said that the Anesthesia Charge physician responded and intubated Patient #3. The Chief of Anesthesia said that a pulse was felt but there was no neurological recovery after the Code. The Chief of Anesthesia said that Patient #3 was transferred to CT and then to ICU. The Chief of Anesthesia said that it is his expectation that a patient is to be placed on the monitors immediately upon arrival in the OR suite if they are premedicated or immediately after Fentanyl is administered. The Chief of Anesthesia said there was a debriefing after the event with all the staff involved and he attended as well. The Chief of Anesthesia said that the Circulating nurse discussed monitoring pre-medicated Patients during transport from Pre-Op to the OR, but he felt this was unnecessary and that many of those monitors do not have alarms that would alert if the patient arrested or was apneic. The Chief of Anesthesia said he is discussing several ideas about this event but no policy or practice changes have been made. The Chief of Anesthesia said that he did not talk to the CRNA one to one about the case, but he spoke to him during the debriefing.

The Surveyors interviewed the CRNA on 10/10/18 at 12:40 P.M. the CRNA said that he was assigned to Patient #3's case and went to Pre-Op with Circulating Room Nurse #1. The CRNA said that Patient #3 had a PICC line in place that was not functioning, so the Attending Anesthesiologist placed a peripheral line. The CRNA said that Patient #3 was anxious so he administered Versed 1 mg IV. The CRNA said that Patient #3 was then transported to the OR suite with Circulating Nurse #3 and that Patient #3 was alert and complaining of pain. The CRNA said that once in the OR suite Patient #3 stayed on the stretcher because he/she was unable to move and the staff called for transfer help. The CRNA said that Patient #3 was complaining of pain so he medicated Patient #3 with 50 mcg of Fentanyl IV. The CRNA said that, as he turned to attach the monitors to Patient #3, Patient #3 again said "I'm in pain" so the CRNA medicated Patient #3 with another dose of Fentanyl 50 mcg IV. The CRNA said that at this time Patient #3 was not on the monitors. The CRNA said that the Circulating Nurse was cleaning Patient #3 and after 2 or 3 minutes that Patient #3 felt stiff and looked different. The CRNA said that he said "Stop" and placed the Ambu-bag (a manual resuscitator used to provide oxygen ventilation) on Patient #3 and placed him/her on the monitors. The monitor showed a "flat line" and there was no pulse. The CRNA said that he asked Circulating Nurse #1 to call the Anesthesia Attending. The CRNA said that the Circulating Nurse #1 called a code and compressions were started. The CRNA said that the Anesthesia Charge physician responded and intubated Patient #3. The CRNA stated that after several minutes that a normal rhythm was noted and that Patient #3 was transported to Cat Scan and then transported to ICU. The CRNA said that a day or two after the meeting there was a Debriefing. The CRNA said that he attended and spoke with the Chief of Anesthesia at the meeting in group setting. The CRNA said that he had to leave the debriefing to care for a patient and did not stay for the entire meeting. The CRNA said he did not discuss the event after that day with anyone and he is unaware if any policy or practice changes have been implemented. The CRNA's account of the incident and time frames are not consistent with accounts from Circulating Nurse #1, Perioperative Nurse #1 or the recorded intraoperative document and the Hospital's adverse event report.

The Surveyors interviewed the Risk Manager on 10/9/18 at 1:37 P.M. The Risk Manager said that she was made aware of the event from an email on 9/6/18. The Risk Manager said that she helped organize the Debriefing after the event. The Risk Manager said that she reviewed the event to see if there was anything that we could change or do differently. The Risk Manager said they decided not to do a Root Cause Analysis because it was determined at the debriefing that there were no systems issues identified or issues with professional practice. There was no investigation conducted.

The Condition of Participation for Anesthesia Services was not met. Based on clinical record review, observations and interviews the Hospital failed to ensure Anesthesia Services Staff monitored a patient during induction and conducted an analysis of an adverse event including other quality or safety indicators related to anesthesia induction.

Findings include:

Based on record reviewed, interviews and observation for one (Patient #3) of 12 sampled patients, the Hospital failed to provide care governing Anesthesia Services in a safe and well-organized manner when a Certified Registered Nurse Anesthetist (CRNA) failed to monitor Patient #3 resulting in Patient #3 experiencing apnea (cessation of breathing), pulselessness requiring cardiopulmonary resuscitation (CPR) and neurological brain damage.

Refer to TAG: A-1002

Based on record reviewed, interviews and observation for one (Patient #3) of 12 sampled patients, the Hospital failed to provide Anesthesia Services in a safe and well-organized manner when a Certified Registered Nurse Anesthetist (CRNA) failed to monitor Patient #3, whose comorbidities included Traumatic Brain Injury (TBI), Obstructive Sleep Apnea and Anemia after Patient #3 was administered Versed (Medication used to relieve anxiety) and two doses of Fentanyl (Opioid medication used to relieve pain) intravenously resulting in Patient #3 experiencing apnea (cessation of breathing), pulselessness requiring cardiopulmonary resuscitation (CPR), and neurological brain damage.

Findings include:

Review of the American Society of Anesthesiologist (ASA) Guidelines (Anesthesiology 2002: 96:1004-17) indicate that (pulse) oximetry (measures oxygen in blood) effectively detects oxygen desaturation and hypoxemia (low oxygen levels) in patients who are administered sedatives/analgesics. All patients undergoing sedation/analgesia should be monitored by pulse oximetry with appropriate alarms if available.

The document titled Surgery Procedure Event 15112, dated 9/5/18, was reviewed on 10/9/18. The document indicated that Patient #3 had multiple co-morbidities including severe anemia and a past history of traumatic brain injury. Patient #3 was scheduled for an orthopedic procedure.

The document titled Anesthesia Pre-Op Note, dated 9/5/18, was reviewed on 10/9/18. The document indicated that Patient #3 had a past medical history that included Adult Obstructive Sleep Apnea (a medical condition where a person stops breathing during sleep) and used a Continuous Positive Airway Pressure (CPAP) machine (a device that keeps the airway open during sleep) at night.

The document titled DARP Form Final Report, dated 9/4/18, was reviewed on 10/09/18. The document indicates that Patient #3 was alert and oriented and responsible to sign his/her consents.

The document indicated that Patient #3 received 50 Micrograms (mcgs) of Fentanyl (narcotic) which appears to have caused a cardiopulmonary arrest. The document indicated that Patient #3 was resuscitated and there was return of spontaneous circulation; however, neurological status was not recovered. The document indicated that the precise course of events was somewhat unclear, Patient #3 may have been in asystole (no heartbeat) for a prolonged period of time, up to 30 minutes. Under the section Resolutions and Outcomes, the document indicated that the severity level of the event was documented as severe/permanent harm.

The document titled Serious Adverse Event 15112, dated 9/5/18, was reviewed on 10/9/18. The document indicated that Patient #3 was pre-medicated with Versed (sedating medication) 1 Milligram (mg), at 11:15 A.M. in the Surgical Day Care area and was then brought into the Operating Room (OR) suite at 11:16 A.M. Upon arrival in the room the Certified Registered Nurse Anesthetist (CRNA) gave Patient #3 two doses of Fentanyl 50 mcg at 11:25 A.M. and 11:28 A.M. in the OR. The document indicated that Patient #3 ceased respirations and no pulses could be felt and a code was called at 11:29 A.M.

The intra-operative document titled (Hospital name removed) Anesthesia dated 9/6/18, at 8:24 (A.M./P.M. not indicated) was reviewed on 10/9/18. The document indicated that Patient #3 was assessed as an American Society of Anesthesiologists (ASA) Class 3 (a patient with severe systemic disease). The document indicated that Patient #3 received Versed 1 mg intravenously (IV) at 11:15 A.M. on 9/5/18. The document indicated that Patient #3 received Fentanyl 50 mcgs IV at 11:25 A.M. and 11:29 A.M. on 9/5/18. The document indicated that the first set of vital signs was recorded at 11:29 A.M. when the code was called (14 minutes after the Versed was administered and 4 minutes after the Fentanyl). The document indicated that the first oxygen saturation was measured as 87.4% (Normal Range 95-100) at 11:35 A.M. (20 minutes after the Versed was administered and 10 minutes after the Fentanyl).

The Surveyors interviewed Circulating Nurse #1 on 10/9/18, at 12:32 P.M. Circulating Nurse #1 said that she was assigned to Patient #3's surgical procedure on 9/5/18. Circulating Nurse #1 said that she met Patient #3 in the Pre-Op department and introduced herself and took report from Perioperative Nurse #1. Circulating Nurse #1 said the CRNA was also in Pre-Op while she received report. Circulating Nurse #1 said that Patient #3 appeared unkempt and thin but was alert, conversational and did not appear to be in any pain. Circulating Nurse #1 said that she did not recall when the CRNA administered Versed 1 mg, but was aware that Patient #3 received Versed. Circulating Nurse #1 said that shortly after receiving report, she and the CRNA transported Patient #3 to the OR. Circulating Nurse #1 said that during the transport from Pre-Op to the OR, Patient #3 was not alert and was mumbling and Circulating Nurse #1 assumed this was due to the Versed. Circulating Nurse #1 said that Patient #3 was not on a monitor, complaining of pain, or talking during the transport to the OR. Circulating Nurse #1 said that when Patient #3 arrived to the OR suite at 11:16 A.M. he/she was positioned next to the procedure table and prepared to be transferred to the procedure table. Circulating Nurse #1 said that Patient #3 was not talking at this time and did not complain of pain or discomfort. Circulating Nurse #1 said that Patient #3 was medicated with Fentanyl and was not on a monitor at this time. Circulating Nurse #1 said that herself, Surgical Tech #1, Surgical Tech #2, and the CRNA were in the room. Circulating Nurse #1 said that when they went to move Patient #3 to the procedure table it was discovered that Patient #3 was incontinent. Circulating Nurse #1 said that Patient #3 was rolled on his/her side to be cleaned and was not on the monitor and was not receiving oxygen. Circulating Nurse #1 said that while cleaning Patient #3 the CRNA said "We have to move him/her". Circulating Nurse #1 said that at that time she noticed that Patient #3 was not breathing and said "I don't think he/she is breathing". Circulating Nurse #1 said that Patient #3 was then placed on the Blood Pressure, Cardiac, and Oxygen saturation monitors and was then administered oxygen for the first time. Circulating Nurse #1 said that she called the Attending Anesthesiologist with the CRNA's phone and told him that they needed help and the CRNA took the phone. Circulating Nurse #1 said that Circulating Nurse #2 came into the room during this time and asked "Is everything was ok?", Circulating Nurse #1 said "No" and Circulating Nurse #2 asked "Is there a pulse?"Circulating Nurse #1 said "No". Circulating Nurse #1 said that Circulating Nurse #2 pushed the Code button on the OR suite wall and then came back to the procedure table and started compressions. Circulating Nurse #1 said that the Anesthesia Charge physician arrived and intubated Patient #3 while the code proceeded, and a pulse was eventually detected and Patient #3 was transferred to Cat Scan and then to the Intensive Care Unit (ICU). Circulating Nurse #1 said that two days after this event that there was a debriefing with all staff involved. Circulating Nurse #1 said that at the debriefing she discussed that Patient #3 was not alert and was mumbling during transport and was not on a monitor and thought it would be a good idea to start monitoring pre-medicated patients during transport from Pre-Op. Circulating Nurse #1 said that there were no practice changes or new policy developed after the debriefing.

The Surveyors interviewed the CRNA on 10/10/18 at 12:40 P.M. The CRNA said that he was assigned to Patient #3's case and went to Pre-Op with Circulating Room Nurse #1. The CRNA said that Patient #3 had a PICC line in place that was not functioning so the Attending Anesthesiologist placed a peripheral line. The CRNA said that Patient #3 was anxious so he administered Versed 1 mg IV. The CRNA said that Patient #3 was then transported to the OR suite with Circulating Nurse #3 and that Patient #3 was alert and complaining of pain. The CRNA said that once in the OR suite Patient #3 stayed on the stretcher because he/she was unable to move and the staff called for transfer help. The CRNA said that Patient #3 was complaining of pain so he medicated Patient #3 with 50 mcg of Fentanyl IV. The CRNA said that, as he turned to attach the monitors to Patient #3, Patient #3 again said "I'm in pain" so The CRNA medicated Patient #3 with another dose of Fentanyl 50 mcg IV. The CRNA said that at this time Patient #3 was not on the monitors. The CRNA said that the Circulating Nurse was cleaning Patient #3 and after 2 or 3 minutes that Patient #3 felt stiff and looked different. The CRNA said that he said "Stop" and placed the Ambu-bag on Patient #3 and placed him/her on the monitors. The monitor showed a "flat line" and there was no pulse. The CRNA said that he asked Circulating Nurse #1 to call the Anesthesia Attending. The CRNA said that the Circulating Nurse #1 called a code and compressions were started. The CRNA said that the Anesthesia Charge physician responded and intubated Patient #3. The CRNA stated that, after several minutes, a normal rhythm was noted and that Patient #3 was transported to Cat Scan and then transported to ICU. The CRNA said that a day or two after the meeting there was a Debriefing. The CRNA said that he attended and spoke with the Chief of Anesthesia at the meeting in group setting. The CRNA said that he had to leave the debriefing to care for a patient and did not stay for the entire meeting. The CRNA said he did not discuss the event after that day with anyone and he is unaware if any policy or practice changes have been implemented.

The Surveyors interviewed the Chief of Anesthesia on 10/10/18 at 9:47 A.M. The Chief of Anesthesia said that he first heard of the event from the Anesthesia Charge physician later in the day on 9/5/18. The Chief of Anesthesia said he was updated by the Anesthesia Charge physician and that several other staff members came to him and updated him on the event. The Chief of Anesthesia said that he did not interview The CRNA at this time because the CRNA had gone home for the day. The Chief of Anesthesia said that the CRNA had pre-medicated Patient #3 in the Pre-Op area because Patient #3 was anxious. The Chief of Anesthesia said that Circulating Nurse #1 and the CRNA transported Patient #3 to the OR and that Patient#3 was complaining of pain. The Chief of Anesthesia said that once inside the OR suite, the CRNA medicated Patient #3 with Fentanyl 50 mcg IV. The Chief of Anesthesia said that Patient #3 again complained of pain while in the OR and was again medicated with Fentanyl 50 mcg and became unresponsive. The Chief of Anesthesia said that Patient #3 was assisted with ventilation by the CRNA and a code was called. The Chief of Anesthesia said that the Anesthesia Charge physician responded and intubated Patient #3. The Chief of Anesthesia said that a pulse was felt but there was no neurological recovery after the Code. The Chief of Anesthesia said that Patient #3 was transferred to CT and then to ICU. The Chief of Anesthesia said that it is his expectation that a patient is to be placed on the monitors immediately upon arrival in the OR suite if they are pre-medicated or immediately after Fentanyl is administered. The Chief of Anesthesia said there was a debriefing after the event with all the staff involved and he attended as well. The Chief of Anesthesia said that the Circulating nurse discussed monitoring pre-medicated Patients during transport from Pre-Op to the OR, but he felt this was unnecessary and that many of those monitors do not have alarms that would alert if the patient arrested or was apneic (not breathing). The Chief of Anesthesia said he is discussing several ideas about this event but no policy or practice changes have been made. The Chief of Anesthesia said that he did not talk to the CRNA one to one about the case, but he spoke to him during the debriefing.

The Surveyors were provided a Peer Review document of the event by Risk Manager #2 at 10:15 A.M. on 10/9/18. Page one of the Peer Review document consisted of a brief paragraph summary and the reviewers comments written below by the Chief Medical Officer. Page two of the Peer Review document consisted of a brief paragraph summary and the reviewers comments written below by Attending Anesthesiologist #2. Page three of the Peer Review document page was a synopsis of the comments on page one and two. There was no indication that nursing or the CRNA were interviewed or quality indicators related to anesthesia were reviewed such as patient monitoring after administration of sedatives and opioids.