| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001000 | (X3) Date Survey Completed 11/16/2023 |
| Name of Provider or Supplier Montgomery Surgical Center Llc | Street Address, City, State 470 Taylor Road, Montgomery, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| Q0162 | FORM AND CONTENT OF RECORD CFR(s): 416.47(b) The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed. Medical records must include at least the following: (1) Patient identification. (2) Significant medical history and results of physical examination (as applicable); (3) Pre-operative diagnostic studies (entered before surgery), if performed. (4) Findings and techniques of the operation, including a pathologist's report on all tissues removed during surgery, except those exempted by the governing body. (5) Any allergies and abnormal drug reactions. (6) Entries related to anesthesia administration. (7) Documentation of properly executed informed patient consent. (8) Discharge diagnosis. This STANDARD is not met as evidenced by: Based on review of medical records (MR), facility policies and procedures, and interviews with facility staff, it was determined the facility failed to ensure: 1. Physicians performing the surgery documented the date and time Routine Standing Orders (RSO's), and Physician's Order Sheet (POS) were signed in twelve of twenty records reviewed. This did affect Patient Identifier (PI) # 11, PI # 17, PI # 19, PI # 8, PI # 4, PI # 12, PI # 20, PI # 2, PI # 18, PI # 16, PI # 13, and PI # 15. 2. The physician signed, dated, and timed the Pre-Operative (Pre-Op) Ophthalmic Medications and Physician's Orders in one of one record reviewed for Cataract surgery. This did affect PI # 12. 3. History and Physical (H & P) Examinations were legible. This affected five of twenty records reviewed including PI # 11, PI # 17, PI # 19, PI # 16, and PI # 13. These deficient practices increase the potential for error and affect all patients served by this facility. Findings include: Facility Policy: Admission to MSC (Montgomery Surgery Center) Review Date: 1/23 Policy: All patients are identified... and medical record preparation is completed during the admission process. Procedure: ...2. ...M. D. (Medical Doctor) standing orders are obtained and signed off by the Pre-Operative registered nurse... Facility Policy: Record Review Date: 1/23 ...Procedure: ...9. All M.D. orders are to be signed off, dated, and timed. 7. PI # 20 was admitted to the facility on 8/17/23 for a Laparoscopy. Review of the POS revealed a photocopied physician signature and no date and time the orders were signed by the physician. An interview was conducted on 11/16/23 at 9:24 AM with EI # 2 who stated the physician does not have RSO, the office staff fax the orders to the surgery center. EI # 2 confirmed the POS did not include the date and time the physician signed the POS. 8. PI # 2 was admitted to the facility on 9/11/23 for a Right Partial Mastectomy and Right Sentinel Lymph Node Biopsy. Review of the POS revealed a photocopied physician signature and no date and time the orders were signed by the physician. An interview was conducted on 11/16/23 at 9:19 AM with EI # 2 who confirmed the POS documentation failed to include the date and time the physician signed the orders. 9. PI # 18 was admitted to the facility on 7/7/23 for a Diagnostic Laparoscopy. Review of the POS revealed a photocopied physician signature and no date and time the orders were signed by the physician. An interview was conducted on 11/16/23 at 9:18 AM with EI # 2 who stated the physician does not have RSO, and orders are faxed to the surgery center. EI # 2 confirmed the POS documentation did not include the date and time the physician signed the POS. 10. PI # 16 was admitted to the facility on 4/28/23 for a Colonoscopy, Possible Biopsy, Possible Polypectomy. Review of the RSO's revealed a "pre-printed" (photocopied) physician signature. There was no date and time the orders were signed by the physician. Review of the 4/28/23 H & P Examination documented by the physician revealed the documentation was not legible. An interview was conducted on 11/16/23 at 9:20 AM with EI # 2 who confirmed the RSO's were already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. EI # 2 confirmed the History and Physical Examination documentation was not legible. 11. PI # 13 was admitted to the facility on 9/19/23 for an Esophagogastroduodenoscopy, Possible Biopsy, Possible Dilatation. Review of the RSO revealed a "pre-printed" (photocopied) physician signature. There was no date or time the orders were signed by the physician. Review of the 9/19/23 H & P Examination document completed by the physician revealed the chief complaint was epigastric discomfort, gastroesophageal reflux. The past medical history and physical examination documentation was not legible. An interview was conducted on 11/16/23 at 9:20 AM with EI # 2 who confirmed the RSO was already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. EI # 2 confirmed the History and Physical Examination documentation was not legible. 12. PI # 15 was admitted to the facility on 2/15/23 for Right Shoulder Video Arthroscopy, Subacromial Decompression, Distal Clavicle Resection and Rotator Cuff Repair. Record review revealed a POS faxed to the facility with instructions for the "operative permit to read", anesthesia type "choice", and a "pre-printed" (photocopied) physician signature. There was no date or time the POS was signed by the physician. Further record review revealed a RSO for the specified surgical group with pre-printed (photocopied) signatures of nine physicians. The ROS had a total of seven individual orders listed per the following: a. Order number one-surgical site clip/prepare per physician preference. b. Order number two-pre-operative antibiotics for eight physicians and NO antibiotics for one named physician during specific procedures. c. Order number five- antibiotic orders for two named physicians, and orders for use of compression device for one named physician. d. Order number six-routine prophylaxis orders for one named physician, specific for dialysis patients, or patient hospitalization within the last year. e. order number seven-orders for compression device use for specific procedures for three named physicians. There was no date and time the physician performing the surgery signed the orders. An interview was conducted on 11/16/23 at 9:15 AM with EI # 2 who confirmed the RSO's were already pre-printed (photocopied) with the physician signature. EI # 2 confirmed the physician performing the surgery did not sign and date the RSO. The ROS described above increased the potential for prep-operative errors. 5. PI # 4 was admitted to the facility on 10/04/23 for Left Knee Manipulation Under Anesthesia. Record review revealed a POS faxed to the facility with instructions for the "operative permit to read", anesthesia type "choice", and a "pre-printed" (photocopied) physician signature. There was no date or time the POS was signed by the physician. Further record review revealed a RSO for the specified surgical group with pre-printed (photocopied) signatures of nine physicians. The ROS had a total of seven individual orders listed per the following: a. Order number one-surgical site clip/prepare per physician preference. b. Order number two-pre-operative antibiotics for eight physicians, and NO antibiotics for one named physician during certain named procedures. c. Order number five- antibiotic orders for two physicians, and orders for use of compression device for one named physician. d. Order number six-routine prophylaxis orders for one named physician, specific for dialysis patients, or patient hospitalization within the last year. e. order number seven-orders for compression device use for specific procedures for three named physicians. An interview was conducted on 11/16/23 at 9:08 AM with EI # 2 who confirmed the RSO's were already pre-printed (photocopied) with the physician signature. EI # 2 confirmed the physician performing the surgery did not sign and date the RSO. The RSO described above, pre-signed by nine physicians and not signed and dated when implemented by the physician performing the surgery, increase the potential for pre-operative errors. 6. PI # 12 was admitted to the facility on 11/14/23 for Cataract Extraction with Intraocular Implant Right Eye. A review of the Pre-Op Ophthalmic Medications orders revealed no documentation the physician signed, dated, and timed the orders. Further review of the MR revealed a Physician's Order with no documentation of the date and time the physician signed the order. An interview was conducted on 11/16/23 at 8:33 AM EI # 1 who confirmed there was no documentation the physician signed dated and timed the orders. 4. PI # 8 was admitted to the facility on 10/10/23 for Septoplasty, Submucosal Resection Turbinoplasty and Anterior Ethmoidectomy. Review of the RSO's revealed a "pre-printed" (photocopied) physician signature. There was no date or time the orders were signed by the physician. An interview was conducted on 11/16/23 at 8:43 AM with EI # 2, who confirmed the RSO's were already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. 1. PI # 11 was admitted to the facility on 9/8/23 for a Colonoscopy, Possible Biopsy, Possible Polypectomy. Review of the RSO's revealed a "pre-printed" (photocopied) physician signature. There was no date or time the orders were signed by the physician. Review of the 9/8/23 H & P Examination document completed by the physician revealed the chief complaint was screening evaluation. The past medical history and physical examination documentation was not legible. An interview was conducted on 11/16/23 at 8:57 AM with Employee Identifier (EI) # 2, Peri-anesthesia Nurse Manager (PNM), who confirmed the RSO's were already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. EI # 2 confirmed the History and Physical Examination documentation was not legible. 2. PI # 17 was admitted to the facility on 6/23/23 for a Colonoscopy, Possible Biopsy, Possible Polypectomy. Review of the RSO revealed a "pre-printed" (photocopied) physician signature. There was no date or time the orders were signed by the physician. Review of the 6/23/23 H & P Examination document completed by the physician revealed the chief complaint was bleeding from rectum. The past medical history and physical examination documentation was not legible. An interview was conducted on 11/16/23 at 8:56 AM with EI # 2 who confirmed the RSO's were already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. EI # 2 confirmed the History and Physical Examination documentation was not legible. 3. PI # 19 was admitted to the facility on 8/7/23 for a Colonoscopy, Possible Biopsy, Possible Polypectomy. Review of the RSO revealed a "pre-printed" (photocopied) physician signature. There was no date or time the orders were signed by the physician. Review of the 8/7/23 H & P Examination document completed by the physician revealed the chief complaint was Anemia. The past medical history and physical examination documentation was not legible. An interview was conducted on 11/16/23 at 8:50 AM with EI # 2 who confirmed the RSO's were already pre-printed (photocopied) with the physician signature and the physician did not sign and date the orders. EI # 2 confirmed the History and Physical Examination documentation was not legible. |