HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports contained documentation of time of surgery for 10 (Patient #1-10) of 10 patients, and type of anesthesia used for four (#3, #4, #7 and #9) of 10 patients. Failure to document the time of surgery did not allow for indication of which surgery was performed in what order in the event of multiple surgeries in one day. Failure to document the type of anesthesia used did not allow for a complete and accurate account of the patient ' s surgical experience. Findings follow.

A. Review of clinical records revealed 10 (#1-10) of 10 operative reports did not contain documentation of the time the surgery was performed. Findings were confirmed by the Operating Room Director on 08/01/12 at 1415.
B. Review of clinical records revealed four (#3, #4, #7 and #9) of 10 operative reports did not contain documentation of the type of anesthesia used. Findings were confirmed by the Operating Room Director on 08/01/12 at 1400.