Initial Comments:
This report is the result of a State licensure survey conducted on March 15, 2024, at the Pennsylvania Eye Surgery Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.
Plan of Correction:
553.25 (1-6) LICENSURE
Discharge Criteria
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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.
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: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.
555.22 (a)(1-2) LICENSURE
Surgical Services - Preoperative Care
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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.
Observations:
Based upon review of facility policy, medical records (MR), and interview of staff (EMP) it was determined that the facility failed to ensure an ASA (physical status) risk level was assigned and the evaluation of the patient's overall health as it would influence the outcome of anesthesia or surgery was completed for five out of 10 medical records (MR1, MR2, MR3, MR4, MR5).
Findings include:
A review of facility policies on March 8, 2024, at approximately 10:30 AM revealed the facility does not have a policy outlining the assignment of an ASA (physical status) under surgical services.
A review of medical records on March 8, 2024, at approximately 10:00 AM revealed that MR1, MR2, MR3, MR4, and MR5 did not contain documentation of the assignment of an ASA (physical status) and revealed no documentation that an ASA level was completed prior to surgery.
An interview on March 8, 2024, at approximately 11:00 AM. with EMP1 confirmed that a physician did not evaluate and document an ASA level (physical status) for MR1, MR2, MR3, and MR4, and MR5.
Plan of Correction:The facility will ensure that an ASA risk level is assigned along with the evaluation of the patient's overall health as it would influence the outcome of anesthesia or surgery.
The policy will be revised to ensure that documentation of the assignment of an ASA level will be completed prior to surgery.
The EMR will now inclcude the ASA risk level for all patients admitted to the facility to include laser patients.
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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