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WELLINGTON REGIONAL MEDICAL CENTER
OPERATING ROOM POLICIES
Tag No.: A0951
Based on record review and interview it was determined the facility failed to develop required policies and procedures related to surgical services provided in the facility. This failure is evident by lack of written protocols addressing the identification of infected and non-infected cases.
The findings included:
Review of the facility policies related to surgical services conducted on 01/14/19 and 01/15/19 revealed no evidence the facility has developed written policies and procedures for the identification of infected and non-infected cases.
Interview conducted with The Director of Surgical Services and The Director of Quality conducted on 01/15/19 at approximately 11 AM confirmed the facility does not have written policies and procedures governing the identification and scheduling of infected and non-infected cases.
OPERATING ROOM REGISTER
Tag No.: A0958
Based on record reviews and interviews, it was determined, the facility failed to ensure the operating room register contained all the required elements. This failure is evident by failure to include the name of person administering the anesthesia.
The findings included:
Review of the facility Operating Room Register dated 06/2018 thru 01/2019 revealed the register lacks documentation of the name of person administering the anesthesia.
Interview conducted with The Director of Surgical Services and The Director of Quality conducted on 01/15/19 at approximately 11 AM confirmed the register does not include the name of the person administering the anesthesia.