Initial Comments:
This report is the result of a State licensure survey conducted on October 12, 2023, at Cherry Tree LLC. 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 (e) LICENSURE
Surgical Services - Preoperative
Name - Component - 00
555.22 Pre-operative Care
(e) Prior to the administration of anesthesia, it is the responsibility of the primary operating surgeon and the person administrating 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 shall be in written policies designating the mechanism to be used to identify each surgical patient.
Observations:
Based on a review of the facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that a physician documented the identification of the patient prior to the start of the procedure for four of 10 medical records reviewed (MR1, MR2, MR3, and MR4).
Findings include:
Review on October 12, 2023, of facility policy "Site Marking and Time-out" revealed "... Policy Statement: Identifying the patient, verifying the intended site, marking the site and performing the time-out are paramount to ensure for the patient's safety during the surgical process. The center will adhere to this policy at all times ... Marking the site: ... The site verified will be documented on the record ... Performing the Time-out: 1. Prior to the beginning of the procedure, the surgeon requests his/ her time-out. 2. Everyone in the room pauses, while the nurse reads out the following:
a.Patients Name
b.Patient's Date of Birth
c.Patient's procedure and site
d.Patient's surgeon
e.Patient's allergies, reactions
f.Patient's implant information if applicable.
g.Patient's special equipment present in room.
3. Everyone must audibly agree with the time-out to proceed. 4. The time-out will be documented with the time it was conducted ..."
A review on October 12, 2023, of MR1, MR3, MR4, and MR5 revealed there was no evidence of documentation in the medical record that a physician identified the patient prior to the procedure.
An interview conducted on October 12, 2023, with EMP1 confirmed that MR1, MR2, MR3, and MR4 did not contain evidence of documentation that a physician identified the patient prior to the start of the procedure.
Plan of Correction:1. The facility changed the documentation to ensure it has a proper place for the surgeon to sign pre-operatively that he / she has identified the patient.
2. The documentation will be reviewed prior to the surgical day to ensure it is the correct paperwork and then it will be reviewed at the end of the day to determine any areas needed for improvement.
3. The documentation will be reviewed at the end of every case day to ensure that nothing is being missed and they are complete and accurate.
4. Daily chart reviews will be completed at the end of the day, by the recovery room nurse to ensure that the charts are complete and accurate.
5. On 10/16/2023, the changes determined from the survey were implemented.
555.24 (g) LICENSURE
Surgical Services - Postoperative
Name - Component - 00
555.24 Post Operative Care
(g) Patients shall be discharged only upon the written signed order of a practitioner.
Observations:
Based on a review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure a physician's order for discharge was written for four of ten medical records reviewed (MR1, MR2, MR3, and MR4).
Findings include:
Review of policy "Discharge Criteria Discharge Criteria ... Policy Statement: All patients must meet discharge criteria prior to being able to leave the center ... Policy: To provide care for the patient recovering from anesthesia and to adequately ensure discharge criteria is met prior to discharge ... Procedure: ... 6. Discharge by a physician ..."
A review conducted on October 12, 2023, of MR1, MR2, MR3, and MR4 revealed no documentation of a physician's order written for discharge from the surgery center.
An interview with EMP1 on October 12, 2023, confirmed that there was no physician order written for discharge in MR1, MR2, MR3, and MR4.
Plan of Correction:1. The discharge order documentation was updated to include a space for the physician to sign, date, and time the discharge order once the patient has met the discharge criteria.
2. The charts will be reviewed prior to the start of the surgical day to ensure it has the proper documentation. The RN will review the chart prior to patient discharge to ensure that physician has signed the discharge order.
3. A chart review will be conducted at the end of every surgical day to ensure there are no deficits with regards to providers signing, dating and timing the documentation.
4. The chart reviews will be conducted at the end of every surgical day to ensure charts are accurate and complete. If there are issues, it will become a study for Quality Assurance and will be addressed immediately.
5. As a result of the inspection, the discharge order area was changed to include a space for the physician to sign, date and time beginning on 10/16/2023.
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