HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure the enforcement of bylaws which required the entry of an Operative Note in the medical record following surgeries for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. A physician note of 4/08/13 at 7:52 AM read, "Going for surgery today morning." A physician's note dictated on 4/08/13 at 3:27 PM read, "Patient going for surgery for thoracic outlet syndrome." A "Brief Op/Inv Procedure Note", dictated on 4/08/13 at 10:12 PM, indicated that the patient underwent a "1st and cervical rib resection, neurolysis" that day. Regarding this note for the 4/08/13 procedure, the medical record did not contain a corresponding more detailed Operative Report.

A review of facility bylaws revealed the following: "Operative reports shall be dictated or written immediately following surgery for outpatients as well as inpatients. The operative report shall include the name of the licensed, independent practitioner(s) who performed the procedure and his or her assistant(s); the name of the procedure performed; a description of the procedures; a detailed description of the findings of the procedure; any estimated blood loss; the specimens removed, the postoperative diagnosis. The completed operative report is authenticated by the surgeon and filed in medical records as soon as possible after surgery. The operative report should be dictated within twenty-four hours after a procedure is performed."

During an interview of the director of nursing on 5/29/13 at approximately 2:15 PM, she confirmed the finding that the surgeon was not in compliance with the bylaws.