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 facility failed to ensure the written instructions provided for preoperative procedures included an understanding 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 April 15, 2025 of MR1, revealed the patient presented to the surgery center on January 9, 2025 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 April 15, 2025 of MR2, revealed the patient presented to the surgery center on August 8, 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 April 15, 2025 of MR3, revealed the patient presented to the surgery center on April 11, 2025 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 April 15, 2025 of MR4, revealed the patient presented to the surgery center on August 28, 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 April 15, 2025 of MR5, revealed the patient presented to the surgery center on November 7, 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 April 15, 2025 of MR6, revealed the patient presented to the surgery center on January 29, 2025 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 April 15, 2025 of MR7, revealed the patient presented to the surgery center on December 31, 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 April 15, 2025 of MR8, revealed the patient presented to the surgery center on October 22, 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 April 15, 2025 of MR9, revealed the patient presented to the surgery center on December 31, 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 April 15, 2025 of MR10, revealed the patient presented to the surgery center on March 18, 2025 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 April 15, 2025, at approximately 3:30 PM with EMP1 confirmed the above findings for MR1, MR2, MR3, MR4, MR5, MR6 and MR7, MR8, MR9 and MR10.
| | Plan of Correction - To be completed: 06/01/2025
Phoenixville Hospital Ambulatory Surgery Center – Limerick nursing staff contact each patient prior to scheduled procedure as part of the patient's pre-admission to go over instructions, what to expect, and answer any questions they may have. During this interaction with the patient, the Pre-admission (PAT) Nurse will notify the patient to the possibility of transfer to a hospital in the event of medical necessity. This information will be documented in the patient's chart in the PAT Notes section of the PAT Navigator within the electronic medical record. Smart phrase created within the electronic medical record to assist with documentation.
One to one staff education on the above process with signed attestation completed May 02, 2025.
An audit of 30 charts a month for compliance with documentation of possibility of transfer to a hospital in the event of medical necessity will be conducted. Monthly audits will be reported to the ASC quality meeting until 3 months of 100% compliance is achieved.
The ASC administrator is ultimately responsible for the corrective actions and ongoing compliance with this standard. All actions will be completed by June 1, 2025.
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