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Based on a review of documentation, and interviews with the staff it was determined that the facility failed to ensure that medical records were complete as 3 of 3 patient medical records reviewed revealed that pre and post treatment evaluations were not documented.

Findings were:
Review of 3 of 3 patient medical records revealed that pre and post treatment evaluations were not documented.

A review of the medical record for patient #1 revealed that one post treatment for patient # 1 did not have the date and time of the evaluation. Additionally pre and post evaluations were not documented for treatments on 12/14/11, 12/18/11,12/20/11, 12/23/11 and 12/27/11 and the post treatment evaluation were not documented on 12/15/11 and 12/21/1.

A review of the medical record for patient #2 revealed that pre treatment evaluations were not documented on 11/14/11 and 11/16/11. Additionally post treatment evaluation was not documented for 12/21/11.

A review of the medical record for patient #3 revealed that pre treatment evaluations were not documented for 6/9/11, 6/7/11, 6/22/11, 6/8/11, 6/14/11, and 6/15/1. Additionally post treatment evaluations were not documented on 6/10/11, 6/13/11, 6/16/11, 7/7/11, 7/5/11 and 7/8/11.

Review of the facility HBO (hyper baric oxygen) policy entitled: "Wound Care Management Program, Policies and Procedures" item E. stated: "The hyperbaric physician scheduled to supervise a patient's HBO treatment will be responsible to perform and document pre and post HBO treatment evaluations on the patient."

In the interviews conducted with the medical director and the HBO (hyper baric oxygen) physician on the afternoon of 03/06/12, it was confirmed that physicians are required to document the pre and post evaluations of all HBO patients receiving treatments. Additionally it was confirmed in the same interview(s) that there was no documentation in the medical records of patients #1, #2, and #3 for the pre and post treatment evaluations as listed above.

Based on review of facility documentation, and interviews with the facility staff, it was determined that the facility failed to report the failure of the oral suction equipment during a code blue for patient #1 as an adverse event.
Findings were:
Review of facility policy # H-PC 05001 stated, Definitions, an event is defined as any occurrence or situation not consistent with the routine operation of the facility and which may have caused or may have the potential for causing injury to patients, visitors, or loss or damage to property. Events include any threat to patient safety."

Review of the facility code critique form stated #5, "In addition there was a problem with the suction machine used in the code resulting in a delay in intubation of the patient. There was not sufficient suction to handle thick secretions. #6 Were there difficulties with the availability and performance of the equipment? See above related to suction and ambu. In addition there was not a crash cart in the HBO treatment room. The crash cart had to be brought to the HBO room. This did not result in any significant delay. There was no central vacuum or central oxygen outlets piped into the HBO. It was necessary to move the patient to the High Observation area to intubate him due to the problem with no suction."
There was no documentation found by or provided to the surveyor indicating that the facility had completed an event report.

In an interview on the afternoon of 03/06/12 with the HBO director and the HBO physician it was confirmed; during the HBO dive of patient #1 on 12/29/11, the patient became unresponsive, the staff responded and a code blue was initiated. The oral suction equipment failed to provide adequate suction to remove the thick secretions from the oral cavity of patient # 1.

In an interview with the DQM on the evening of 03/06/12 at the facility it was confirmed by the DQM that an incident/event report had not been completed. The DQM stated the incident was not reported as an event, because a plan of corrections had been implemented after reviewing the code critique form.