HospitalInspections.org

Based on interview, facility policy and record reviews the facility failed to ensure the staff follow the facility policy of accepting verbal orders infrequently as in "Urgent Situations" (in which immediate written or elecronic communication is not feasible) in six of twelve open records and six of eleven closed records. The facility census was 12.

Findings included:

Record review of Patient # 1's medical chart showed four of six orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #2's medical chart showed five of seven orders were verbal orders:
thus verbal orders were not infrequent as policy required.

Record review of Patient #3's medical chart showed five of twelve orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #4's medical chart showed three of six orders were verbal orders:
thus verbal orders were not infrequent as policy required.

Record review of Patient #5's medical chart showed twelve of seventeen orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #6's medical chart showed four of seven orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #7's medical chart showed ten of fifteen orders were verbal orders:
thus verbal orders were not infrequent as policy required.

Record review of Patient #8's medical chart showed eight of twelve orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #9's medical chart showed three of six orders were verbal orders:
thus verbal orders were not infrequent as policy required.

Record review of Patient #10's medical chart showed five of seven orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #11's medical chart showed eight of thirteen orders were verbal orders: thus verbal orders were not infrequent as policy required.

Record review of Patient #12's medical chart showed six of twelve orders were verbal orders: thus verbal orders were not infrequent as policy required.

During an interview on 1/3/11 at 1:30 PM, Director of Nursing stated the physicians come over in the mornings to see patients and do not usually return to see patients until the next day. He/she confirmed the physician's habits were to give verbal orders as the rule and not the exception as provided by facility policy.

Record review of the facility policy "Verbal and Written Orders" issued 6/2006, showed in part the following information:

-Verbal Orders: Will only be accepted in Urgent Situations in which immediate written or electronic communication is not feasible.