HospitalInspections.org

Based on document review and interview Surgical Services failed to maintain a complete and up to date operating room register for 40 of the 40 days reviewed.

Findings:

A review of the operating room registers from 7/01/2024-8/09/2024 was conducted on 8/12/2024 at 1:00 PM with the Interim QAPI Director, Staff #3. A review of the register revealed the names of each employee who cared for the patient throughout the Perioperative period. The Perioperative period includes pre-operative (before surgery), intra-operative (in the operating room), and post-operative (after surgery) time. There were no credentials or positions (i.e., circulator or scrub) documented next to any of the case staff listed on the register.

An interview was conducted with RN Staff #3 and Surgical Services Director, RN Staff #5 on 8/12/2024 at 1:30 PM. RN Staff #3 and RN Staff #5 confirmed the operating room register did not identify who the scrub (Certified Surgical Technologist, Registered Nurse, or Licensed Practical Nurse assisting the surgeon during the operation) or circulator (an RN that is responsible for the patient care outside the sterile field during the surgery) was during the patient's surgical procedure.