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Based on review of the Operative Log and interview, it was determined the Operative Log did not contain the required elements. Failure to include all required elements in the Operating Room Log did not allow the Facility to track and trend potential problems including infections, adverse reactions and staff incidents. Findings follow:
Review of the Operative Log received from the Vice President of Peri-Operative and Women's and Children's Services at 1045 on 06/16/15 revealed it did not contain the type of anesthesia and the name of the person administering anesthesia, the pre and post -operative diagnoses and the age of the patient.
During an interview with the Vice President of Quality and Nurse Executive at 1200 on 06/16/15 she verified the above findings.

Based on clinical record review and interview it was determined the Facility failed to ensure the time of the operative procedure was included in the operative report for four (#1, #4, #5 and #8) of ten (#1-#10) patients. Failure to ensure the operative time was noted in the operative report did not allow knowledge of which operation was performed at what time in the event of multiple surgeries in one day. The failed practice was likely to affect Patients #1, #4, #5 and #8 on 06/16/15. Findings follow:

Review of the operative reports for four (#1, #4, #5 and #8) of ten (#1-10) patients revealed the operative report did not contain the time the surgery was performed.

During an interview with the Clinical Information Abstractor #1 at 1025 on 06/16/15 she verified the above findings.