HospitalInspections.org

A complaint investigation was conducted 05/30/17 through 06/01/17. Based on medical staff bylaws review, Medical Record review and staff interview, the facility surgical staff failed to ensure an operative report was written immediately after a procedure in 1 of 4 surgical records reviewed. (Patient # 8)

The findings included:

Review on 06/01/17 of the "Section IV Rules and Regulations of the Bylaws Medical and Dental Staff [Facility Name]" revealed,"... 7. Operative Reports: All operative reports and invasive procedures performed shall be fully described in reports by the operating surgeon or a designee immediately after the operative or invasive procedure. ..."

Review on 06/01/17 of the medical record for Patient #8 revealed he was admitted on 05/22/17 after a fall. Review revealed Patient #8 underwent a Thoracic (spine) decompression and dorsal spinal abscess drainage on 05/23/17. Medical record review revealed a consent for "posterior decompression T1-T6 Thoracic1 to Thoracic 6" was signed and dated 05/23/17 at 0826 by the patient. Continued review of the medical record revealed a "Physician Progress Note" dated 05/24/17 at 0944 stated "...POD (post operative day) #1 s/p post decompression T1-T6 ..." Further review revealed no immediate post-operative note of the surgical procedure performed on 05/23/17 available as of the 06/01/17 record review.

Interview on 06/01/17 at 1245 with AS #1 (administrative staff) revealed the post-operative report was to be written immediately after the procedure based on the facility bylaws. Continued interview confirmed that an immediate post-operative note was not in the record for Patient #8. Interview revealed the Surgical Chief was made aware of the missing report. Further interview revealed the surgeon for Patient #8 was in a procedure, but would write the post-operative note upon completion. Interview revealed the requirement for an immediate post-operative note would be discussed during a future medical staff meeting.