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Based on review of Medical Staff Rules and Regulations,hospital policy, medical records review, and staff interviews, the facility failed to ensure an immediate post-operative report was completed for 4 of 10 records reviewed (Patients #7, #8, #5, and #10).

Findings included:

Review of the "Rules and Regulations of the Bylaws of the Medical Staff " amended effective 06/16/2018 revealed "... 24. Operative reports shall be dictated or documented in the medical record within the timeframe set by Hospital policy and contain a description of the findings, the technical procedures used, the specimen removed, the postoperative diagnosis, and the name of the primary surgeon and any assistants. If the report is not done, the Department Chair or Division Chief will be notified. A brief Operative Note shall be entered in the medical record within the timeframe set by Hospital policy to provide pertinent information until the full Operative Note is completed. ..."

Review of the policy titled "Medical Record Completion and Administrative Reassignment" latest review date 01/20/2017 revealed, "... 7. Operative reports should be entered in the medical record immediately after the surgery and contain a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis, and the name of the primary surgeon and any assistants. ... 8. If the Operative Report is dictated, a brief Operative Note shall be entered in the record immediately after surgery to provide pertinent information until the dictated Operative Report is transcribed. ..."

1. Medical record review of Patient #7 revealed an 86 year-old male admitted on 03/07/2019 for an Arthrodesis (cervical 2/cervical 3 - thoracic 2 decompression and fusion) under general anesthesia. Review of the record revealed the surgery started on 03/07/2019 at 1320 and ended at 1635. Review of the medical record on 04/10/2019 (36 days after surgery) revealed no evidence of a documented operative note.

Interview on 04/10/2019 at 1220 with RN #2 (operating room registered nurse staff education) revealed she was unable to locate an operative report in Patient #7's medical record. Interview revealed an Immediate Operative Report was not completed.

Telephone interview on 04/10/2019 at 1640 with MD #1 (attending surgeon) revealed "The residents are supposed to do a brief operative note. It was not done."

2. Medical record review of Patient #8 revealed an 47 year-old female admitted on 04/04/2019 for an Arthrodesis (cervical 3 - 7 anterior cervical decompression and fusion) under general anesthesia. Review of the record revealed the surgery started on 04/04/2019 at 0913 and ended at 1402. Review of the medical record on 04/10/2019 (6 days after surgery) revealed no evidence of a documented operative note.

Interview on 04/10/2019 at 1220 with RN #2 (operating room registered nurse staff education) revealed she was unable to locate an operative report in Patient #8's medical record. Interview revealed an Immediate Operative Report was not completed.

Telephone interview on 04/10/2019 at 1640 with MD #1 (attending surgeon) revealed "The residents are supposed to do a brief operative note. It was not done."

3. Medical record review of Patient #5 revealed a 6 year-old female admitted on 04/08/2019 for a Tonsillectomy and Adenoidectomy (T and A removal). Record review revealed the surgery started on 04/08/2019 at 0939 and ended at 0953. Record review revealed an Brief Operative Note electronically documented on 04/08/2019 at 0921, 18 minutes prior to the start of the surgery and 32 minutes prior to the end of surgery.

Telephone interview on 04/11/2019 at 1100 with MD #3 revealed the immediate operative report should be written immediately after surgery. Interview confirmed the immediate operative report for Patient #5 was written 32 minutes prior to the end of surgery.



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4. Review of the medical record revealed Patient #10 was a 64 year old female admitted to the facility on 03/29/2019 for revision of a left total knee arthroplasty (surgical replacement of weight bearing surfaces of the joint with artificial parts). Review of the operative record revealed Patient #10 arrived in the operative suite on 03/29/2019 at 1114, the surgical procedure started at 1207, and surgery was completed at 1439. Further review revealed Patient #10 was transferred out of the operative suite on 03/29/2019 at 1440. Review of the medical record revealed the presence of a completed operative report dated 03/29/2019 at 2301, and the report had been electronically signed by the operating physician at 2313 (8 hours and 34 minutes after surgery). Review revealed Patient #10 was discharged home on 04/01/2019 at 1235. Review failed to identify the presence of an immediate post-operative report.

Interview on 04/11/2019 at 1542 with the Accreditation Manager revealed she and a member of the perioperative services department had attempted to locate an immediate post-operative report. Interview confirmed absence of an immediate post-operative report for Patient #10.

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