HospitalInspections.org
Bringing transparency to federal inspections
MERCY MEDICAL CTR
OPERATING ROOM REGISTER
Tag No.: A0958
Based on record review, the Hospital failed to ensure that the OR register accurately reflected the surgical procedure performed on one of ten patients (Patient #1).
Findings included:
The Consent for Surgical or Diagnostic Procedure, dated 5/14/12, indicated that Patient #1 consented to a left-sided facetectomy at the L5 - S1 level, with possible translumbar interbody fusion capstone, posterior lateral fusion and pedicle screw fixation.
The Operative Note, dated 5/14/12, indicated that Patient #1's surgical procedure included: posterior interbody and posterolateral fusion at L4-L5 and L5-S1 levels, biomechanical intervertebral body device (capstone) at the L4-L5 and L5-S1 levels and pedicle screw fixation at the L4-S1 levels.
Review of the OR Register, dated 5/14/12, indicated that Patient #1's surgical procedure was performed at the L5-S1 level and did not include the L4-L5 level.