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Based on record review and interview, the facility failed to ensure Patient 2's operative report describing techniques, findings, and tissues removed or altered was written or dictated immediately following surgery and signed by the surgeon.

Findings:

A review of Patient 2's medical record revealed the patient was admitted to the facility on March 24, 2011.

Patient 2's Operative Report disclosed the patient underwent a surgical procedure (wound excisional debridement down to tendon tissues) on March 31, 2011. However, the Operative Report was authenticated on April 4, 2011 at 10 a.m., which was 3 days after the surgical procedure.

During an interview with Employee 2 on April 4, 2011 at 11:25 a.m. she stated the operative report should have been completed immediately following surgery and signed by the surgeon.