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Based on interview and record review, the facility failed to ensure:

1. An operative report was completed for one sampled patient (Patient 12); and,

2. The immediate postoperative notes and/or the operative reports were complete for two sampled patients (Patients 10 and 16).

This resulted in incomplete operative reports and important surgical information not being available to other facility personnel having to provide care for these patients postoperatively.

Findings:

1. On November 30, 2016, the record for Patient 12 was reviewed. Patient 12 was admitted to the facility on November 28, 2016, for scheduled surgery to his left knee.

The comprehensive operative report was not present in the record. The Director Patient Safety/Quality (DPSQ) also looked for the operative report in the record.

The DPSQ was able to locate an immediate postoperative note in the Admission Note section of the record. The immediate postoperative note was a brief description and did not contain all of the details to provide comprehensive information of the surgery. There was no documentation describing techniques and findings of the operative procedure.

On November 30, 2016, at 2 p.m., the DPSQ and the Director Health Information Management (DHIM) were interviewed. After searching the record themselves, the DPSQ and the DHIM stated, a comprehensive or finalized postoperative report was not in the record.


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2a. On November 29, 2016, the record for Patient 10 was reviewed. Patient 10 was admitted to the facility on November 15, 2016, with diagnoses including rheumatoid (disease that causes chronic inflammation of the joints) and osteoarthritis (joint disease that results from breakdown of joint cartilage and underlying bone) of the right knee.

The "Intraoperative Nursing Record" dated November 15, 2016, at 10:58 a.m., indicated specimens of the right knee bone and tissue were ordered.

The "Postoperative Note: General" dated November 15, 2016, at 1:19 p.m., indicated the procedure performed was a right total knee arthroplasty (surgical procedure to replace the weight bearing surface of the knee joint).

The "Postoperative Note: General" did not delineate which specimens were removed.

The "Operative Report" dated November 15, 2016, at 3:54 p.m., indicated the procedure performed was a right total knee arthroplasty.

The "Operative Report" did not delineate which specimens were removed.

During an interview with the Director Perioperative Services (DPOS), on November 30, 2016, at 10:30 a.m., she reviewed the record for Patient 10, and was unable to find documentation of specimens removed on the "Operative Report" or the immediate postoperative note. The DPOS stated the "Operative Report" and the immediate postoperative note, if done by the physician, should have delineated which specimens were removed.

b. On November 30, 2016, the record for Patient 16 was reviewed. Patient 16 was admitted to the facility on November 25, 2016, for abdominal pain and subsequently had surgery to remove her gallbladder.

The intraoperative record dated, November 25, 2016, documented a specimen as the "gallbladder and contents."

The immediate postoperative note by Physician 10, did not indicate tissue removed or indicate that a specimen was obtained.

On November 30, 2016, at 1:52 p.m., Executive Director for Ancillary Services (EDAS) was interviewed. EDAS confirmed a specimen was not documented on the postoperative report.

The facility Medical Staff Rules and Regulations, revised May 12, 2015, revealed, "...Operative Procedure Reports, Operative reports should be dictated by the primary surgeon immediately after surgery, and dated/signed by the surgeon. Operative reports shall contain the name of the primary surgeon and any assistants, indications and name of specific surgical procedure performed, type of anesthesia administered, complications if any, description of techniques and findings, the specimens removed, blood loss, prosthetic devices, grafts, tissues, transplants, or devices implanted if any, and the pre-operative and post-operative diagnosis..."