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Based on interview, review of medical records and review of facility policy, it was determined the facility failed to ensure the operative report was written or dictated immediately following surgery for seven (7) of ten (10) sampled patients, Patient #1, # 2, #3, #4, #6, #7 and #10.

The findings include:

Review of facility policy, "Medical Record Documentation and Completion," policy number A05-045, effective date 10/11/10, revealed operative reports for inpatients and outpatients would be written or dictated immediately following the procedure. It further revealed when the full operative report could not be entered immediately into the patient's medical record after the procedure, the following would be included in the medical record before the patient was transferred to the next level of care: 1) a post-operative progress noted that utilized form J2006; or 2) a written post-operative progress note that included the date of surgery or procedure, the name of the primary surgeon(s) and his/her assistants, the name of the procedure performed and a description of each procedure finding, the post-operative diagnosis, any estimated blood loss, and any specimen(s) removed.

1. Review of the medical record for Patient #1 revealed an admission date of 09/13/12 with diagnoses of Hypoplastic Left Heart Syndrome. Further review of the record revealed Patient #1 underwent surgical procedures on 09/20/12 (Norwood Procedure with Sano Modification using six (6) millimeter Gore-Tex Shunt from the Right Ventricle to the Pulmonary Artery; Atrial Septectomy; Ligation and Resection of Patent Ductus Arteriosus and Cannulation for Extracorporeal Membrane Oxygenation (ECMO) cardiopulmonary support on 09/20/12. Additional review revealed the operative report was not dictated until 09/22/12, and there was no documentation of a written post-operative progress note.

2. Review of the medical record of Patient #2 revealed he/she was admitted on 07/11/12 with a diagnosis of Hypoplastic Left Heart Syndrome. Further review of the record revealed he/she underwent surgical procedures on 07/11/12 (Glenn Cavopulmonary Shunt; Ligation of Sano Shunt, Patch Repair of Pulmonary Artery Confluence and Redo Sternotomy) with a stop time of 8:34 PM. Additional review of the operative report revealed it was dictated on 07/16/12 at 1:18 PM, and there was no documentation of a written post-operative progress note.

3. Review of the medical record of Patient #3 revealed he/she was admitted on 09/27/12 with a diagnosis of Congenital Heart Disease, Pulmonary Atresia with Ventricular Septal Defect. Further review of the record revealed he/she underwent surgical procedures on 10/02/12 (Central Shunt 3.5 millimeter Gore Tex Graft from Aorta to Pulmonary Artery and Ligation of Patent Ductus Arteriosus) with a stop time of 11:22 AM. Additional review of the operative report revealed it was dictated on 10/04/12 at 10:16 AM, and there was no documentation of a written post-operative progress note.

4. Review of the medical record of Patient #4 revealed he/she was admitted on 08/29/12 with diagnoses of Ventricular Septal Defect, Ostium Secundum Atrial Septal Defect and Trisomy-21 (Down's Syndrome). Further review of the record revealed he/she underwent surgical procedures on 08/29/12 (Pericardial Patch Closure of Ventricular Septal Defect, Primary Closure of Atrial Septal Defect, Tricuspid Valve Annuloplasty and Repair of Aortic Insufficiency Secondary to Patch Closure of Ventricular Septal Defect) with a stop time of 3:35 PM. Additional review of the operative report revealed it was dictated on 09/06/12 at 9:39 PM, and there was no documentation of a written post-operative progress note.

5. Review of the medical record of Patient #6 revealed an admission date of 04/02/12 with a diagnosis of Transposition of the Great Arteries. Further review of the record revealed Patient #6 underwent a surgical procedure, Arterial Switch, on 04/16/12. Additional review revealed the operative report was not dictated until 04/20/13. On 04/25/12 Patient #6 underwent another procedure, Mediastinal Exploration and Sternal Debridement and Application of a Wound Vacuum. Further review revealed the operative report was dictated on 04/29/12, and there was no documentation of a written post-operative progress note.

6. Review of the medical record of Patient #7 revealed an admission date of 04/12/12 with a diagnosis of Imperforate Anus and Congenital Heart Disease. Further review revealed Patient #7 underwent a procedure on 05/07/12, Atrial Septectomy and 3.5 millimeter Central Systemic to Pulmonary Shunt Review of the operative report revealed it was not completed until 05/08/12 at 9:41 PM, and there was no documentation of a written post-operative progress note.

7. Review of the medical record of Patient #10 revealed an admission date of 08/15/13 with a diagnosis of Left Lower Extremity Abscess. Further review revealed Patient #10 underwent a procedure on 08/16/13 of Incision and Drainage of Left Lower Extremity Abscess with Placement of two (2) Vessel Loop Drains; the procedure ended at 2:07 PM. Review of the operative report revealed it was not dictated until 7:07 PM, and there was no documentation of an immediate written post-operative progress note.

Interview with the Corporate Director of Health Information Management, on 08/16/13 at 6:19 PM, revealed each medical record was monitored for completeness after discharge but not during the admission. She further revealed if the record was not complete when reviewed after discharge, the Physician had thirty (30) days to complete it and if not completed within this timeframe, the Physician was placed on suspension with his/her admitting privileges removed.

Interview with the Director of Enterprise Accreditation and Regulatory Compliance, on 08/16/13 at 6:10 PM, revealed no documentation could be found for an immediately written postoperative progress note for the above seven (7) patients and agreed it was a requirement per facility policy.