555.22 Pre-operative Care
(c) Written instruction for preoperative procedures, which have been approved by the medical staff, shall be given to the patient or responsible person, and shall include: (1) Applicable restrictions upon food and drink before surgery (2) Special preparations to be made by the patient (3) The required proximity of the patient to the ASF for a specific time following surgery if applicable. (4) An understanding that the patient may require admission to the hospital in the event of medical need. (5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.
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Observations:
Based on a review of medical records (MR), and interview with staff (EMP), it was determined the written instructions provided for preoperative procedures failed to include an understanding that the patient may require admission to the hospital in the event of medical need for ten of ten medical records reviewed (MR1, MR2, MR3, MR4,MR5, MR6, MR7, MR8, MR9 and MR10).
Findings include:
A review on January 17, 2024 of MR1, revealed the patient presented to the surgery center on October 2, 2023, for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR2, revealed the patient presented to the surgery center on October 2, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR3, revealed the patient presented to the surgery center on October 12, 2023, for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR4, revealed the patient presented to the surgery center on October 12, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR5, revealed the patient presented to the surgery center on January 17, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR6, revealed the patient presented to the surgery center on November 22, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR7, revealed the patient presented to the surgery center on August 10, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR8, revealed the patient presented to the surgery center on August 3, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR9, revealed the patient presented to the surgery center on June 8, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on January 17, 2024 of MR10, revealed the patient presented to the surgery center on April 26, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
An interview conducted on January 17, 2024, at 2:15 PM with EMP2 confirmed the above findings for MR1, MR2, MR3, MR4, MR5, MR6 and MR7, MR8, MR9 and MR10.
| | Plan of Correction - To be completed: 03/01/2024
GI-ASC will correct deficiency #552C related to the patient receiving written instructions for preoperative procedures which have been approved by the medical staff. The current approved written instructions for GI-ASC includes applicable restrictions related to food and drink prior to procedure, special preparations, procedure dependent, the approximate time expected to be at the ASF, and the requirement for a responsible person to escort the patient home after sedation. The current pre-procedure instructions did NOT include notification regarding the patient understanding that the patient may require admission to the hospital in the event of medical need. The medical staff has approved the addition of the statement, "In the event of medical need, you may require hospital admission". This statement has been added to the patient instructions within the section where the procedure is explained to the patient. This explanation is initially reviewed by the provider and a second time by the practice staff when the procedure is scheduled and instructions are provided. The ASC shall retain a copy of instructions at the ASC for review, as indicated. During the admission process to the ASF the assessment nurse reviews the pre procedure instructions with the patient having the patient attest to receiving such instructions. This is documented in the patient record. The ASF administrator shall be responsible for ensuring that staff who provides patient instructions is educated on the updated instructions set and shall complete instruction to staff by 2/9/2024. The ASF administrator shall be responsible for ongoing oversight of the correct patient instructions being delivered to the patients. She shall monitor this by performing random chart audits of the ASC medical record. She will audit 10 medical records per week for 30 days to ensure the patient does attest to receiving such instructions. The updated instruction sets has been completed as of 1/29/2024. The updated instruction set and chart audit shall be reported to the Governing Board at the next meeting not yet scheduled.
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