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Based on record review, review of facility policy and staff interviews, the Critical Access Hospital (CAH) failed to ensure a physican examined 4 (patient 26, 28, 29, 30) of 6 surgical patients immediately before surgery to evaluate the risk of the procedure to be performed. The CAH also failed to ensure an anesthesia provider examined 4 (patient 26, 28, 29, 30) of 4 before surgery to evaluate the risk of anesthesia. This failed practice has potential to effect all surgical patients treated at the CAH. The facility had 347 surgical patients for fiscal year 24.

Findings are:

A. Review of Patient 26's medical record (6/24/25 at 11:15 AM) revealed patient 26 was admitted 1/23/25 at 5:46 AM for a left total knee replacement (artificial parts are used to replace damaged ends of bones). The physician evaluation for risk of procedure was signed by the physician on 1/23/25 at 9:01 AM The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 7:45 AM.
- Review of Patient 28's medical record (6/25/25 at 9:00AM) revealed patient 28 was admitted 3/20/25 at 7:34 AM for bilateral myringotomy with tube placement (tubes inserted behind the ear drum to help drain fluid backup in the middle ear) and bilateral adenoidectomy (removal of adenoid glands located behind the nose above the roof of the mouth). The physician evaluation for risk of procedure lacked a signature at time of the record review. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 8:21 AM.
- Review of Patient 29's medical record (6/26/25 at 8:00AM) revealed patient 29 was admitted 3/21/25 at 11:15 AM for esophagogastroduodenoscopy (EGD, procedure using a small flexible tube with camera to look inside the mouth down to the stomach and start of small intestine) and colonoscopy (procedure using a long flexible tube with a camera to look inside the colon or large intestine).The physician evaluation for risk of procedure was signed by the physician 3/21/25 at 11:18 PM. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 12:26 PM.
- Review of Patient 30's medical record (6/25/25 at 1:20 PM) revealed patient 30 was admitted 4/4/25 at 7:30 AM for Minimally Invasive Surgery right foot; derotational osteotomies of toes 2,3,4 (procedure to straighten the toes). Hemiphalangectomy right 2nd toe distal interphalangeal joint (removal of part of bone at the joint closest to the tip of the toe. The physician evaluation for risk of procedure was signed by the physician 4/21/25 at 11:26 AM. The anesthesia provider examination lacked a time when the note was completed. Review of surgery intraoperative note revealed surgery started at 8:57 AM.

B. Review of policy Evaluation of Surgical Patients by Anesthesia (Last date reviewed 7/1/2024) revealed, qualified practitioners who perform surgery at CAH will examine the patient immediately before surgery to evaluate the patient's risk for surgery.
- Qualified anesthesia providers shall examine each patient before surgery to evaluate the risk of anesthesia. This will be documented on the anesthesia record.

C. Interview (6/26/25 at 12:45 PM) with the Chief Nursing Officer (CNO) revealed her agreement of confirmation of missing documentation for each patient identified (patient 26, 28, 29 and 30).