Observations:
Based on review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the provider performed and documented the identification of the patient prior to the surgical procedure in two of six medical records reviewed (MR1 and MR2).
Findings include:
A request was made on August 17, 2023, to EMP2 for the facility's policy regarding patient identification. No policy or document was provided that addressed the provider performed and documented the identification of the patient prior to the surgical procedure.
A review on August 17, 2023, of MR1, admitted on January 20, 2023, for a Left index Revision Amputation, revealed no documentation the surgical provider performed and documented the identification of the patient prior to the procedure.
A review on August 17, 2023, of MR2, admitted on February 20, 2023, Amputation of the LEFT thumb, index finger, ring finger, small finger, revealed no documentation the surgical provider performed and documented the identification of the patient prior to the procedure.
An interview conducted on August 17, 2023, at 3:12 PM with EMP3 confirmed MR1 and MR2 did not contain documentation that the surgical provider performed and documented the identification of the patient prior to the surgical procedure.
| | Plan of Correction - To be completed: 12/15/2023
Plan of Correction:
The Surgery Center at Penn Medicine University City (PMUC), a facility of Penn Presbyterian Medical Center (PPMC), leadership wrote and approved a policy and process, ASF 4.0, that reinforces the standards that require that before the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administering anesthesia to properly identify the patient and the procedure to be performed and to document this identification in the patient's medical record. This procedure is now in writing in the policy and designates the mechanism to identify each surgical patient before anesthesia is administered, including when a case may be canceled.
The Surgery Center at PMUC is taking the following measures to prevent reoccurrence:
The physician/proceduralist performing the procedure will document in the electronic medical record (EMR) that they have identified the patient before administering an anesthetic. In particular, the physician will write and sign a note in the EMR confirming that they have identified the patient. This note will contain the date and time that the identification occurred.
The Surgery Center Medical Director will communicate, via email with a read receipt or a signed attestation, to all surgeons/ proceduralists a copy of the policy with the requirements of the regulation and reiterate the expectation of documenting in the EMR that they identified the patient before the administration of an anesthetic.
Additionally, if a procedure is canceled for medical reasons after the patient has entered an operating/procedure room, but before the start of the intended procedure, the EMR must contain a note that the patient had been identified by the person administering the anesthesia and the intended surgeon.
The Surgery Center will monitor its performance by the following procedure:
A random audit of 30 medical records a month from various specialties will be conducted as directed by the Surgery Center Medical Director or designee to verify compliance in identifying the patient before the administration of anesthesia.
The Surgery Center Administrator or designee will monitor compliance and notify the Surgery Center Medical Director of discrepancies.
Auditing of compliance will be monitored by the Surgery Center Administrator or designee until three consecutive months with a compliance rate of 100% is achieved.
Compliance results will be reported as part of quality assurance and performance improvement activity to the Surgery Center Quality Committee and the ASF Coordinating Committee, a subcommittee of the PPMC Board of Trustees until compliance is sustained. The Surgery Center Quality Committee will also determine any further audits over time to verify continued compliance.
The completion date for the Plan of Correction is 12.15.2023.
Title of person responsible for the Plan of Correction: Surgery Center Medical Director
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