Initial Comments:
This report is the result of a State Re-licensure survey conducted onsite on March 20, 2024, at Bryn Mawr Medical Specialist Endoscopy. 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:
555.22 (c)(1-5) LICENSURE
Surgical Services - Preoperative Care
Name - Component - 00
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.
Observations:
Based on a review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure the written instructions provided for preoperative procedures included an understanding the patient may require admission to the hospital in the event of medical need for ten of ten medical records reviewed (MR1, MR2, MR3, MR4,MR5, MR6, MR7, MR8, MR9 and MR10).
Findings include:
A review on March 20, 2024 of MR1, revealed the patient presented to the surgery center on February 21, 2024, for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR2, revealed the patient presented to the surgery center on February 16, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR3, revealed the patient presented to the surgery center on December 12, 2023, for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR4, revealed the patient presented to the surgery center on November 27, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR5, revealed the patient presented to the surgery center on January 2, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR6, revealed the patient presented to the surgery center on November 30, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR7, revealed the patient presented to the surgery center on December 15, 2023 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR8, revealed the patient presented to the surgery center on January 2, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR9, revealed the patient presented to the surgery center on January 5, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
A review on March 20, 2024 of MR10, revealed the patient presented to the surgery center on February 12, 2024 for a procedure. There was no documented evidence of the patient being provided with preprocedural instructions that included an understanding that the patient may require admission to the hospital in the event of medical need.
An interview conducted on March 20, 2024, at 2:45 PM with EMP1 confirmed the above findings for MR1, MR2, MR3, MR4, MR5, MR6 and MR7, MR8, MR9 and MR10).
Plan of Correction:The administrative director has reviewed the facility Informed consent and preoperative instructions and acknowledges it does not include notification to patient regarding admission to the hospital in the event of a medical emergency . The corrective action is as follows:
The administrative director will revise the facility Informed Consent, adding "In the rare event of a medical need during and /or after the procedure, you may require admission to the hospital."
The governing body will review and approve the changes to the Informed Consent proposed by the administrative director.
To continually protect the patient community served by the facility, the revised Informed Consent will be reviewed and approved by the governing body annually to ensure it is updated and applicable to our patient population.
The administrative director and governing body are responsible for this plan of corrections. This plan of corrections will be completed by May 6, 2024.
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