553.25 Discharge Criteria
A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.
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Observations:
Based on review of facility policy, medical records review (MR), and interview of staff (EMP) it was determined that the facility failed to ensure physical status criteria was met before the discharge of patients and that facility policy does not adequately address discharge criteria for five out of ten medical records reviewed (MR1, MR2, MR3, MR4, and MR5).
Findings include:
A review on March 8, 2024, at approximately 11:30 AM, of facility policy "Post-Op Procedures" without reference dates, revealed "PACU nurses take vital signs and note post-operative reactions, including: a. nausea and vomiting; b. bleeding; c. vaso-vagal or shocking reaction, which includes changes in color or vital signs."
A review of medical records on March 8, 2024, at approximately 10:00 AM revealed MR1, MR2, MR3, MR4, and MR5 did not contain documentation that physical status criteria was met prior to discharge.
An interview on March 8, 2024, at approximately 12:00 PM with EMP1 confirmed the lack of documentation of the patients physical status criteria and that the policy did not adequately address discharge criteria for (MR1, MR2, MR3, MR4, and MR5).
| | Plan of Correction - To be completed: 04/04/2024
The facility will ensure that the policy for a patient's physical status criteria be revised in the "Post-op Procedures" policy found in the Surgical Services chapter. The patient's physical status will be assesssed and met and results documented in the EMR for all patients admitted to the facility, prior to discharge, to include all laser surgery procedures.
To ensure the problem does not recur the ASA classification has been added to the appropriate section of the EMR.
Monitoring will be conducted through chart audits daily, weekly and quarterly until compliance is met. Then quarterly monitoring thereafter.
The DON will oversee the nursing staff audits.
The results will be reported to the Board.
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