HospitalInspections.org

Based on record review, policy and procedure (P&P) review the hospital failed to ensure complete orders were received prior to completing surgical procedure in 4 of 10 surgical cases reviewed. This had the potential to affect all patients having surgery during the survey, 4/15/2013 = 27 and 4/16/2013 = 29.


On 4/16/2013 a review of pt's #5, 7, 8 and 10 records were completed with Clinical Informatics (CI) F.

At 12:20 PM a review of pt. #5's record was completed. The record showed pt. #5 had right hip surgery on 4/15/2013. The physician order does not have a physician signature.

At 12:28 PM a review of pt. #7's record was completed. The record showed pt. #7 had a laparoscopic appendectomy on 2/20/2013. There is no physician order.

At 12:37 PM a review of pt. #8's record was completed. The record showed pt. #8 had left knee surgery on 2/12/2013. The physician order does not have a physician signature.

At 12:51 PM a review of pt. #10's record was completed. The record showed pt. #10 had laparoscopic hernia surgery on 2/18/2013. There is no physician order, only a case request.
The above findings were cinfirmed with CI F at the time of review.

Review of P&P titled Orders for Patient Care, dated 7/2012 was completed on 4/17/2013 at 2:30 PM. The P&P states in part 2) All other patient care orders shall contain the following: d. Name and/or signature of the prescriber.