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 (MR), and staff interview (EMP), the facility failed to ensure that patients met the required discharge criteria prior to discharge for 2 out of 20 medical records reviewed (MR 11, MR17).
Findings include:
A review of facility policy "YAG Laser Procedure" last revised 1/9/11, under procedure steps revealed "... 1. After informed consent is obtained, a pre/post-operative form is completed with vital signs and the nursing assessment ... 8. Patient is then escorted to the recovery area where post op vital signs will be obtained, and physician orders completed ..."
A review of the facility policy "Admission, Discharge, and Transfer" with no revision date revealed "... The patient must meet the following discharge criteria: Vital signs - BP, HR, Temp, and RR are within normal for patient's age or at preoperative levels for the patient, oxygen saturations at baseline levels ..."
A review on April 9, 2024, of the "Laser Surgery-Local/Topical Anesthesia" form revealed that the form did not include documentation of the patient's temperature.
Review of MR11 on April 9, 2024, revealed the patient's temperature was not assessed prior to discharge from the facility.
Review of MR17 on April 9, 2024, revealed the patient's temperature was not assessed prior to discharge from the facility.
Interview with EMP1 on April 9, 2024, confirmed the medical records did not contain documentation that the patients were assessed for temperature per policy, prior to discharge.
| | Plan of Correction - To be completed: 04/30/2024
It is the responsibility of the Clinical Director to make sure the facility staff follows center policy regarding patient discharge criteria. The following POC has been established:
1. All OSI laser forms will be revised with a temperature documentation line.
2. All OSI Pre and Post operative personnel and medical staff will be educated about the addition of the temperature requirement. This will be documented via staff education sign-in record. This will be completed by April 30, 2024.
3. All laser charts will be audited for temperature compliance documentation on the Pre/Post op assessment sheet by the Clinical Director or designee weekly and will be completed by May 31, 2024. Charts are audited randomly every quarter for compliance with results being reported and documented in the quarterly QA meetings/minutes which are forwarded to the Med Executive Committee for review. Goal is 100% compliance.
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