Initial Comments:
This report is the result of a State Licensure survey conducted onsite on August 21, 2024, and completed offsite on August 27, 2024, at Bucks County Surgical Suites. It was determined that 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:
555.33 (d)(1) LICENSURE
Anesthesia Policies and Procedures
Name - Component - 00
555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(1) A patient requiring anesthesia shall have a pre-anesthesia evaluation by a practitioner, with appropriate documentation of pertinent information regarding the choice of anesthesia.
Observations:
Based on review of medical records (MR) and interview with staff (EMP) it was determined the facility failed to obtain informed consent for administration of local anesthesia for four (4) of four (4) records reviewed. (MR5, MR6, MR7, MR8)
Findings include:
Review on August 21, 2024, of MR5 revealed the patient was injected with 5 milliliters (ml) of 1% lidocaine as a local anesthetic for a left L5 and S1 transforaminal epidural steroid injections. Further review of MR5 revealed no completed anesthesia consent form or specify administration of local anesthesia noted on the patient's procedural consent.
Review on August 21, 2024, of MR6 revealed the patient was injected with 5 milliliters (ml) of 1% lidocaine as a local anesthetic for a L5-S1 interlaminar epidural steroid injections. Further review of MR6 revealed no completed anesthesia consent form or specify administration of local anesthesia noted on the patient's procedural consent.
Review on August 21, 2024, of MR7 revealed the patient was injected with 5 milliliters (ml) of 1% lidocaine as a local anesthetic for a C7-T1 interlaminar epidural steroid injection. Further review of MR7 revealed no completed anesthesia consent form or specify administration of local anesthesia noted on the patient's procedural consent.
Review on August 21, 2024, of MR8 revealed the patient was injected with a local anesthetic for a right middle finger trigger release. Further review of MR8 revealed no completed anesthesia consent form or specify administration of local anesthesia noted on the patient's procedural consent.
Interview on August 21, 2024, at approximately 12:50 PM, with EMP1 confirmed the above findings and confirmed an anesthesia consent is not obtained for local anesthetic cases completed at the facility.
Plan of Correction:Local anesthetic is frequently given by surgeons both pre-op and intra-op during the closure of the incision.
We have updated our surgery consent, shown below at 5.), to include local anesthetic injections. The change will take effect immediately with this approval.
The change on the consent form reads as follows:
*My signature below constitutes my acknowledgement and full understanding that:
1.) I have read, or have had read to me, the foregoing & I agree to all parts of it.
2.) The procedure(s) have been adequately explained to me by my physician.
3.) I authorize consent to perform the procedure(s), & any additional procedure(s), deemed advisable by my physician.
4.) I authorize consent to the administration of anesthesia for the said procedure(s) by contracted anesthesia provider of the facility. I understand a separate anesthesia consent form will be completed while at the facility.
5.) I authorize consent to the administration of local anesthetic injection and/or a regional nerve block by the physician performing the procedure(s) consented above. I understand the anesthesia provided may be injected near nerves resulting in a loss of sensation, feeling and/or movement of a specific limb or area.
All charts are reviewed daily for accuracy and completion. Abnormal findings are reported quarterly during the safety meeting.
The administrator is responsible for the implementation of the POC.
555.33 (d)(8)(i-v) LICENSURE
Anesthesia Policies and Procedures
Name - Component - 00
555.33 Anesthesia policies and procedures
(d) Anesthesia procedures shall provide at least the following:
(8) Before discharge from the ASF, a patient shall be evaluated for proper anesthesia recovery by an anesthetist, the operating room surgeon, anesthesiologist or dentist. Depending on the type of anesthesia and length of surgery, the postoperative check shall include at least the following:
(i) level of activity
(ii) respirations
(iii) blood pressure
(iv) level of consciousness
(v) oxygen saturation by pulse oximetry.
Observations:
Based on review of medical records (MR), review of facility policy, and interview with staff (EMP) it was determined the facility failed to complete a post anesthesia evaluation prior to discharge of a patient who received local anesthesia for four (4) of four (4) MRs reviewed. (MR5, MR6, MR7, MR8)
Findings include:
Review on August 21, 2024, of MR5 revealed the patient received local anesthesia and did not have a documented post anesthesia evaluation completed by the surgeon prior to discharge.
Review on August 21, 2024, of MR6 revealed the patient received local anesthesia and did not have a documented post anesthesia evaluation completed by the surgeon prior to discharge.
Review on August 21, 2024, of MR7 revealed the patient received local anesthesia and did not have a documented post anesthesia evaluation completed by the surgeon prior to discharge.
Review on August 21, 2024, of MR8 revealed the patient received local anesthesia and did not have a documented post anesthesia evaluation completed by the surgeon prior to discharge.
Review on August 21, 2024, of facility policy " 3.8 Discharge from BCSS by Physician " , dated July 16, 2018, revealed " ...Policy: Each patient will be examined by a physician prior to discharge as determined by the physician ...The post anesthesia evaluation will be completed prior to discharge ... "
Interview on August 21, 2024, at approximately 12:54 PM, with EMP1 confirmed the above findings.
Plan of Correction:All patients receiving anesthesia from an anesthesia provider are evaluated and discharged by the anesthesiologist. Patients not seen by anesthesia and only receiving local anesthetic injections will be evaluated and discharged by the physician performing the procedure.
The local procedure record has been updated to include:
1. Patient has been evaluated by the physician post procedure, and
2. Post-Anesthesia complications are absent and the pt. has met the discharge criteria as per PA Code 553.25
Physician Signature ___________
Discharge Time: ____________
The updated local procedure form will be implemented upon acceptance and approval of the changes presented.
All charts are reviewed daily for accuracy and completion. All abnormalities are reported quarterly during the safety committee meeting.
The administrator is responsible for the implementation of the POC.
|