555.22 Pre-operative Care
(a) Pertinent medical histories and physical examinations, and supplemental information regarding drug sensitivities documented day of surgery or one of the following:
(1) If medical evaluation, examination and referral are made from a private practitioner's office, hospital or clinic, pertinent records thereof shall be available and made part of the clinical record at the time the patient is registered and admitted tot he ASF. This information is considered valid no more than 30 days prior to the date of surgery.
(2) A practitioner shall examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. The information shall be clearly documented in the medical record.
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Observations:
Based upon review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that each patient was evaluated and assigned an ASA (physical status) for 3 of 10 medical records reviewed (MR3, MR4, and MR5).
Findings include:
A review of facility policy "ASA Classification" on June 13, 2024, with a most recent revision date of October 13, 2022, revealed "ASA classification will be established for all surgical patients."
On June 13, 2024, a review of medical records MR3, MR4, and MR5 revealed these records did not contain documentation of each patient being assigned an ASA level (physical status) prior to undergoing a procedure.
On June 13, 2024, an interview with EMP1 confirmed that a physician did not evaluate and document an ASA level (physical status) for MR3, MR4, and MR5.
| | Plan of Correction - To be completed: 06/18/2024
In response to summary statement of deficiencies from our recent PA Department of Health, DAAC survey on June 14, 2023, we submit the following plan of corrections for consideration:
For prefix S552A, Regulation 555.22 "Surgical Services – Preoperative Care", our plan of correction is:
- A process audit was conducted by the Administrator and the Interim Director of Nursing on 6/13/24 to determine where gaps in the process occurred.
- On 6/14/24, Interim Director of Nursing met with the Anesthesia Director. An amendment to the preoperative process was created where the Anesthesia Director (or his designee) will, upon preoperative review of the local anesthesia patient's chart, assign an ASA level (physical status) for each local anesthesia patient and clearly document the ASA level in the "Comments" section of the "Procedure Pass" tab on the patient's chart.
- On 6/17/24, Interim Director of Nursing amended facility's "ASA Classification" policy to include establishing protocol for all patients instead of "anesthesia patients." Board approval of this policy change was received via email vote on 6/17/24.
- All staff and providers were notified of this change via email on 6/17/24.
- Effective 6/17/24, PAT nurse/Interim Director of Nursing will verify that ASA level was assigned to all local anesthesia patients prior to date of surgery. If an ASA level is not assigned, Administrator or Interim Director of Nursing will be notified. Administrator/Interim Director of Nursing will notify LOG practice and Anesthesia Director that will be cancelled if ASA score is not assigned 24 hours prior to procedure.
- Starting 6/17/24, Administrator/Interim Director of Nursing or designee will audit 100% of local anesthesia patient charts for 30 days for compliance with ensuring that patients were assigned an ASA level. Audit results will be reported to the facility's Governing Body at the next meeting.
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