555.22 Pre-operative Care
(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities documented day of surgery or one of the following: (1) If medical evaluation, examination and referral are made from a private practitioner's office, hospital or clinic, pertinent records thereof shall be available and made part of the clinical record at the time the patient is registered and admitted tot he ASF. This information is considered valid no more than 30 days prior to the date of surgery. (2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.
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Observations:
Based on review of facility policy, medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure pertinent medical histories were performed within thirty days of the procedure for 4 of 10 medical records reviewed (MR1, MR2, MR3, and MR4).
Findings include:
On January 18, 2024, at approximately 10:30 AM a review of facility policy titled "History, Physical, and Pre-Surgical Assessment" with an effective date of October 31, 2023 revealed "A comprehensive medical history and physical assessment will be completed not more than 30 days before the date of the surgery. No patient will be transported to the operating room without a completed signed, dated, and timed H&P."
On January 18, 2024, at approximately 10:00 AM. a review of medical records revealed MR1, MR2, MR3, and MR4 did not contain documentation of pertinent medical histories performed within thirty days of the procedure.
MR1 revealed the comprehensive medical history was completed January 31, 2023. The date of the procedure was March 9, 2023.
MR2 revealed the comprehensive medical history was completed May 2, 2023. The date of the procedure was July 5, 2023.
MR3 revealed the comprehensive medical history was completed January 31, 2023. The date of the procedure was March 18, 2023.
MR4 revealed the comprehensive medical history did not contain documentation of a date. The date of the procedure was February 6, 2023.
January 18, 2024, at approximately 10:30 AM an interview with EMP1 confirmed comprehensive medical histories were not performed within thirty days of the procedure for MR1, MR2, MR3, and MR4 did not contain a date.
| | Plan of Correction - To be completed: 01/31/2024
Tag: S 552A The plan of correction is prepared in compliance with state/federal regulations and is intended as Berkshire Eye Surgery Center's (the "center") credible allegation of compliance. The submission of the plan of correction is not an admission by the facility that it agrees that the citations are correct or that it violated the law. Organization Minutes: The confidential and privileged minutes are being retained at the facility for agency review and verification if required. Exhibits: All exhibits including revisions to Medical Staff Bylaws, reviewed/revised or promulgated policies and procedures, documentation of staff and medical staff training/education are retained at the facility for agency review and verification upon request. Tag: S 552A 555.22 Surgical Services-Preoperative Care Policy & Procedures: Clinical Director reviewed and revised Policy "History, Physical and Pre-Surgical Assessment" to include "Medical/Anesthesia History Form will be completed by the patient or surrogate within 30 days of the scheduled surgery date. Upon arrival to the Center if the Medical/Anesthesia History Form is out of date the patient/surrogate will be required to complete a new Medical/Anesthesia History form pre-operatively before admission into the Pre-operative area." The revised policy was presented to the Governing Body (GB) for approval. Policy amended on 01/31/2024 after GB Approval. Completion date: 01/31/24 Other Corrective Actions: Clinical Director implemented a process where the Medical/Anesthesia History form date of completion will be checked for timeliness during the pre-chart nurse review two days prior to surgery. If the date of completion is not within 30 days of scheduled surgical procedure the patient will be asked to arrive 10 minutes earlier on the day of surgery to complete a new Medical/Anesthesia History form. Notification to the patient will be documented under "Needed" items on the pre-procedure call checklist. Completion date: 02/16/24 Training: 1. Clinical and Business Office Staff has received education on Policy revision during a staff meeting on 01/26/24. The staff was required to verbalize understanding of the policy and attest to the fact they received a copy of the policy by initialing the policy in the new/revised policy binder. Staff not present at the meeting are required to read the meeting minutes and initial revised policy in the new/revised policy binder. 2. The staff was shown the Medical/Anesthesia History Form and where to find the date of completion on the form. 3. Medical Staff, Anesthesia Staff and Physician office, where Medical/Anesthesia History form originates from, were notified to the Policy change on 01/30/24. Completion date: 02/16/24 Monitoring: Clinical Director will audit 10 charts weekly for 1 month followed by an audit of 30 charts per month for 3 months for compliance with patient/surrogate completing the Medical/Anesthesia History form within 30 days of scheduled surgery. Once 3 consecutive months of 100% compliance has been achieved random audits will be performed as part of the monthly QAPI chart audits. Audit reports will be reported quarterly to the Quality Committee and Medical Executive Committee. Completion date: 02/16/24 ongoing
Responsible Person(s): All clinical staff is responsible to prevent this occurrence. Clinical Director, Administrator and all nursing staff.
Disciplinary Action: Non-compliance with corrective action by center staff will result in immediate remediation and appropriate disciplinary action in accordance with the center's Human Resources policies and procedures.
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