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 provide patients with written preoperative instructions prior to surgical procedures for seven of seven medical records reviewed (MR1, MR3, MR6, MR7, MR8, MR9 and MR10) and failed to provide patients with written preoperative instructions that included the required proximity of the patient to the facility for a specific time following the procedure if applicable or an understanding that the patient may require admission to the hospital in the event of medical need for two of two medical records reviewed (MR4 and MR5).
Findings include:
A request was made on April 24, 2023, to EMP1 for the facility policy for the provision of written preoperative instructions to patients prior to surgical procedures. No document was provided.
1) A review on April 24, 2023, of MR1, admitted December 27, 2022, for an upper gastrointestinal (GI) endoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure. The patient was transferred to the hospital emergently with chest tightness and difficulty breathing.
A review on April 24, 2023, of MR3, admitted April 3, 2023, for an upper GI endoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
A review on April 24, 2023, of MR6, admitted March 29, 2023, for an upper GI endoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
A review on April 24, 2023, of MR7, admitted March 15 2023, for an upper GI endoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
A review on April 24, 2023, of MR8, admitted March 31, 2023, for a colonoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
A review on April 24, 2023, of MR9, admitted February 21, 2023, for a colonoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
A review on April 24, 2023, of MR10, admitted March 6, 2023, for a colonoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed no documentation the patient received written instructions prior to the procedure.
An interview conducted on April 24, 2023, at 1:28 PM with EMP1 confirmed the facility did not have a policy for the provision of written preoperative instructions to patients prior to surgical procedures. EMP1 confirmed there was no documentation that MR1, MR3, MR6, MR7, MR8, MR9 and MR10 received written preoperative instructions prior to the procedure.
2) A review on April 24, 2023, of MR4, admitted April 10, 2023, for a colonoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed written instructions were provided prior to the procedure. The preoperative instructions provided to the patient did not contain information regarding the required proximity of the patient to the facility for a specific time following the procedure if applicable or an understanding that the patient may require admission to the hospital in the event of medical need.
A review on April 24, 2023, of MR5, admitted April 11, 2023, for a colonoscopy procedure under monitored anesthesia care (MAC) anesthesia revealed written instructions were provided to the patient prior to the procedure. The preoperative instructions provided to the patient did not contain information regarding the required proximity of the patient to the facility for a specific time following the procedure if applicable or an understanding that the patient may require admission to the hospital in the event of medical need.
An interview conducted on April 24, 2023, at 2:53 PM with EMP2 confirmed the written preoperative instructions provided to MR4 and MR5 did not include information regarding the required proximity of the patient to the facility for a specific time following the procedure if applicable or an understanding that the patient may require admission to the hospital in the event of medical need.
| | Plan of Correction - To be completed: 08/11/2023
Written instructions are provided to the patients by the practice staff. The center staff RNs call patients prior to their procedures to complete pre-calls. During the pre-call, the patient is asked if they have any questions to the written instructions that they have received from the practice staff and the nurse provides the clarification. It is documented in the EMR that the patient has received instructions for: "preparation for the procedure, center location, must have a driver, NPO, no smoking or vaping after midnight, bring inhalers and list of updated medications, insurance cards, photo ID and any special instructions are documented (such as hold blood thinners, diabetic medication, etc.).
Staff are being educated to ensure this section is completed for each patient. The monthly nursing Peer Review includes that this section is completed for each patient that is reviewed. The Director of Nursing and administrator will be responsible to ensure this is documented. Any concerns will be communicated to the Board of Managers.
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