This report is the result of a full State Licensure survey conducted on April 23, 2019, at the Center for Specialized Surgery. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health ' s Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.
Plan of Correction:
555.33 (d)(5) LICENSURE
Anesthesia Policies and Procedures
Name - Component - 00
555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(5) A patient receiving anesthesia shall have an anesthesia record maintained. This shall include a record of vital signs and all events taking place during the induction of, maintenance of and
emergence of anesthesia, including the dosage and duration of anesthesia agents, other drugs and IV fluids.
Based on review of facility documents and medical records (MR), and interview with staff (EMP), it was determined the facility failed to document the doses of anesthesia medication given to patients and the time anesthesia medication was administered to the patient during surgery for five of five medical records reviewed (MR1, MR2, MR4 MR5 and MR11).
Review on April 23, 2019, of policy "Documentation of Anesthesia Care," last reviewed January 1, 2019, revealed: "Policy: Documentation a factor in the provision of quality care and is the responsibility f an anesthesia provider ... 2. Preanesthesia (time-based record of events) ... c. Doses of drugs and agents used, times and routes of administration and any adverse reactions ..."
Review on April 23, 2019, of MR1, MR2, MR4, MR5 and MR11, revealed these patients had procedures at the facility between December 20, 2018, and April 1, 2019. Further review revealed no documented evidence of the specific times and dosages of sedation medications that were administered to these patients during their surgical procedures.
Interview on April 23, 2019, at 1:00 PM, with EMP1 confirmed there was no documented evidence of the specific times and dosages of sedation medications that were administered to the patients listed in MR1, MR2, MR4, MR5 and MR11.
Plan of Correction:
The facility will have all anesthesiologists record the dosage of medication given during surgery on their anesthesia record.
The facility will have all anesthesiologists' record the time medication was given during surgery on their anesthesia record.
In order to bring the center to fully correct the deficiency, the current Anesthesia Record used at the center will be updated to include proper documentation of dosages of the medications given and time medication was administered during surgery.
To assure continuous monitoring of all charts, the Medical Record Checklist will include "Anesthesia record shows dosage and time of all medication given".
The clinical coordinator will instruct all anesthesiologists/staff about the required documentation of dosage and time drugs were administered and re-educate them on our policy "Anesthesia Policy 40.4". The clinical coordinator will review with the staff, the changes made to the Anesthesia Record to reflect the proper record of drugs/dosage and time. Clinical Coordinator will educate pre/post op clinical staff on proper use of the new Medical Record Checklist.
Daily monitoring of 100% of charts will be done by pre/post clinical staff by utilizing the Medical Record Checklist. This process will continue for a minimum period of six months. This period may be extended if compliance has not been reached.
Quality Improvement study will be done by Clinical Coordinator to audit overall compliance with the program.
The current monthly CQI chart audit of 10% of patients coming through the facility will include "Anesthesia Record shows dosage and time of all medication given" is correctly documented on the Anesthesia Record and Medical Record Checklist. This is done by the CQI Coordinator.
If non-compliance is noted, offender will be re-educated. If continued non-compliance, peer review and review from the board will be done and disciplinary action may be taken according Medical Bylaws.
Results of all audits will be reported to the Medical Advisory Board, Patient Safety Committee and Governing Board.
The Director will have overall responsibility for the plan of correction to be implemented.
The plan of correction will be fully in place by 6/7/2019