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Based on record review, policy review, and interview the hospital failed to ensure that when verbal orders are used, they must be used infrequently and failed to ensure that verbal orders are authenticated and countersigned by the prescribing practitioner within 24 hours of receipt as required per hospital policy. This deficient practice poses an increased risk of miscommunication that could contribute to medication or other errors, resulting in a patient adverse event.


Findings Include:

Document review of the hospital's policy titled, "Verbal and Telephone Orders," revised 02/2022 showed, " ...The use of verbal orders (including telephone or other oral orders) shall be minimized. Verbal/Telephone orders shall be processed in accordance with medical staff rules and regulations and as described in this policy ...Orders will be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt ..."


Patient 1

Review of Patient 1's current medical record showed they were admitted on 03/16/22. Review of documents titled, "Physician's Orders" showed a total of 20 orders with 15 documented as verbal orders. (75% of the orders were verbal). Seven of 15 verbal orders were missing a physician signature. The prescribing physician failed to sign two of 15 verbal orders within 24 hours as required by facility policy.


Patient 2

Review of Patient 2's current medical record showed they were admitted on 03/09/22. Review of documents titled, "Physician's Orders" showed a total of 20 orders with 15 documented as verbal orders. (75% of the orders were verbal). Two of 15 verbal orders were missing physician signature. The prescribing physician failed to sign seven of 15 verbal orders within 24 hours as required per facility policy.


Patient 3

Review of Patient 3's current medical record showed they were admitted on 03/13/22. Review of documents titled, "Physician's Orders" showed a total of 34 orders with 24 documented as verbal orders. (70% of the orders were verbal). Nine of 24 verbal orders were missing a physician signature.


Patient 4

Review of Patient 4's current medical record showed they were admitted on 02/08/22. Review of documents titled, "Physician's Orders" showed a total of 66 orders with 51 documented as verbal orders. (77% of the orders were verbal). Nine or 51 verbal orders were missing a physician signature.


Patient 5

Review of Patient 5's current medical record showed they were admitted on 03/08/22. Review of documents titled, "Physician's Orders" showed a total of 33 orders with 18 documented as verbal orders. (55% of the orders were verbal). Seven of 18 verbal orders were missing a physician signature.


Patient 6

Review of Patient 6's current medical record showed they were admitted on 02/15/22. Review of documents titled, "Physician's Orders" showed a total of 52 orders with 21 documented as verbal orders. (40% of the orders were verbal). Six of 21 verbal orders were missing a physician signature.


Patient 7

Review of Patient 7's current medical record showed they were admitted on 03/01/22. Review of documents titled, "Physician's Orders" showed a total of 41 orders with 26 documented as verbal orders. (63% of the orders were verbal). Ten of 26 verbal orders were missing a physician signature.


Patient 8

Review of Patient 8's current medical record showed they were admitted on 03/25/22. Review of documents titled, "Physician's Orders" showed a total of 18 orders with 14 documented as verbal orders. (78% of the orders were verbal). One of 14 verbal orders were missing a physician signature.


Patient 9

Review of Patient 9's current medical record showed they were admitted on 03/17/22. Review of documents titled, "Physician's Orders" showed a total of 37 orders with 21 documented as verbal orders. (57% of the orders were verbal). Seven of 21 verbal orders were missing a physician signature.


Patient 10

Review of Patient 10's current medical record showed they were admitted on 03/01/22. Review of documents titled, "Physician's Orders" showed a total of 35 orders with 17 documented as verbal orders. (49% of the orders were verbal). Six of 17 verbal orders were missing a physician signature.


Patient 11

Review of Patient 11's current medical record showed they were admitted on 03/01/22. Review of documents titled, "Physician's Orders" showed a total of 36 orders with 23 documented as verbal orders. (64% of the orders were verbal). 21 of 23 verbal orders failed to show a physician signature.



During an interview on 03/30/22 at 2:00 PM, Staff A, Chief Clinical Officer stated that the facility does not have electronic documentation and the physicians have no way to access the patient chart unless they are on-site. She stated she was not aware of the facility's policy on verbal orders required physician authentication (verification) within 24 hours of receipt. Staff A verified that the hospitals policy states verbal orders are to be used infrequently.

During an interview on 04/01/22 at 11:00 AM, Staff I, Wound Care Physician, stated that he attempts to write his own wound care orders but if verbal orders are given, the orders are then put into a box and he will sign them when he rounds, which is twice a week. He stated he was not aware that policy states the physician must sign verbal orders within 24 hours.

During an interview on 03/30/22 at 1:05 PM, Staff D, Wound Care Nurse, stated that there are two groups of wound care physicians and that each of the two physicians will round twice weekly. One physician rounds on Monday and Thursday, and the other physician rounds on Tuesday and Friday. Staff D stated, "I fill out the wound order form as prescribed by the doctors and the form gets put into the dictation room. The physicians should sign the orders within policy timeframe but sometimes they are not signed for a week ...The doctors round and are gone by the time I finish performing wound care and putting in orders. I/we need to find a better way to make sure orders are signed off by physicians within the time required by policy (24 hours) so we don't continue to get dinged for not following policy ..."