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Based on interview and record review, the hospital's Governing Body failed to ensure that members of the medical staff complied with the hospital policies. For 4 of 21 sampled patients (Patient 15, 16, 17, and 19), the hospital failed to ensure that the prescribing physicians responsible for providing telephone and written orders, authenticated these orders with legible signatures, dates and times, as indicated in the hospital's policies, "Medications - Telephone, Verbal, or Written Orders," and "Medication Error Reduction Program," established March 5, 2015.

This failure had the potential to contribute to medication errors which could increase the risk of patient harm due to use of medications that were not intended by the prescribing physician.

Findings:


1. A record review of Patient 15 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 8:30 AM. The record review indicated that Patient 15 was admitted on January 4, 2015 with the diagnosis of Diverticulitis (an inflammation of the colon) with rectal bleeding. A physician telephone order provided to a Registered Nurse (RN) on January 6, 2015 at 4:55 PM, for an anti-allergy and anti- nausea medication order, was not authenticated by the physician (62 days after the telephone order was received by the RN.) The IICN stated, "Missed and that the physician who provided the telephone order should have signed it."


2. A record review of Patient 16 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 9:30 AM. The record review indicated that Patient 15 was admitted on January 6, 2015 with the diagnosis of shortness of breath and bronchitis (inflammation of the mucus membrane of the bronchial tubes of the lungs.) There were multiple physician telephone orders were provided to the RN on the following dates: January 6, 2015 at 10:55 PM, January 7, 2015 at 12:55 AM, January 08, 2015 at 3:25 PM, January 9, 2015 at 10:35 AM, and January 10, 2015 at 11:30 AM, for multiple medication orders that contained an illegible physician signature with no date and time when the order was signed by the prescribing physician.


On January 6, 2015 at 10:55 AM, the physician order was signed with no date and time. The January 7, 2015 at 12:55 AM, the physician order was signed with no date and time. The January 08, 2015 at 3:25 PM, the physician order was signed 4 days after the order was provided to the RN with no time indicated when the telephone order was signed. The January 9, 2015 at 10:35 AM, physician order was signed 3 days after the order was provided to the RN with no time when signed. The January 10, 2015 at 11:30 AM, the physician order was signed 15 days after the order was provided to the RN with no indicated time when the telephone order was signed.


During the interview with the IICN on March 11, 2105 at 9:30 AM, the IICN confirmed and stated that the physician signatures were illegible, and were signed untimely, either with no date and or time when signed.


3. A record review of Patient 17 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 10:30 AM. The record review indicated that Patient 17 was admitted on January 14, 2015 with diagnosis of bronchitis (inflammation of the mucous membrane of the bronchial tubes of the lungs) and status post (s/p) fall. A physician telephone order provided to an RN on January 17, 2015 at 2:00 PM for pain management and to discontinue the foley (a urinary catheter inserted into the urinary tract for the purpose of draining the urine from the urinary bladder) catheter, was authenticated on February 2, 2015 with no time (16 days after the telephone order was received by the RN.) The IICN confirmed and stated that the telephone order was not signed timely and there was no time indicated when it was signed.


4. A record review of Patient 19 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 11:30 AM. The record review indicated that Patient 19 was admitted on February 3, 2015 for complaint of chest pain. A multiple physician telephone orders were provided to an RN for multiple medications on February 3, 2015 at 9:40 PM, February 4, 2015 at 9:55 AM, February 5, 2015 at 5:27 AM, February 5, 2015 at 9:23 AM, February 5, 2015 at 9:05 PM, and February 5, 2015 at 9:25 PM.


The physician orders for February 3, 2015 at 9:40 PM contained an illegible physician signature (9 days after the telephone order was provided) and did not include the time when the order was signed by the prescribing physician. The February 4, 2015 at 9:55 AM contained an illegible physician signature (8 days after the telephone order was provided) and did not include the time when the order was signed by the prescribing physician. The February 5, 2015 at 5:27 AM, February 5, 2015 at 9:23 AM, February 5, 2015 at 9:05 PM, and February 5, 2015 at 9:25 PM, contained an illegible physician signature (7 days after the telephone orders were provided) and did not include the time when the order was signed by the prescribing physician. The IICN confirmed and stated that the telephone orders were not signed timely and the physician's signatures were illegible.


During an interview with the hospital's Chief Nursing Officer/Chief Operating Officer (CNO/COO) on March 13, 2015 at 10:00 PM, the CNO/COO confirmed and stated that the physicians have been instructed and asked to signed telephone orders in a timely manner.


A record review was conducted on March 11, 2015 at various times, of the hospital policy and procedure titled, "Medications - telephone, verbal, or written orders, "revised 0n January 2012. The policy indicated, "The prescribing practitioner must sign the written record of the verbal/telephone order within 48 hours of giving the order."


Further record review of the hospital policy and procedure titled, "Medication Error Reduction Program," established March 5, 2015, Policy Guidelines: 10 - Telephone/Verbal Orders, indicated under number 9, "All telephone medication orders must be authenticated, timed, and dated by the Practitioner within 48 hours ..."

Based on interview and record review, the hospital failed to implement their policy titled, "Pain Management," revised on September 2013, and failed to ensure that the patient was re-assessed for the effectiveness of the administered pain medication, for 1 of 21 sampled patients (Patient 16). This failure had the potential for Patient and 16 experiencing worst pain and not having the right to be free from pain.

Findings:

A record review was conducted with the Informatics/Infection Control Nurse (IICN) on March 11, 2015 at 9:30 AM of Patient 16. This patient was admitted on January 6, 2015 with diagnosis of shortness of breath and bronchitis (inflammation of the mucus membrane of the bronchial tubes of the lungs). Further review of the clinical record showed that Patient 16 received Acetaminophen 650 mg (milligram) orally on January 6, 2015 at 7:58 PM for complaint of intermittent aching pain to the head area with a pain scale of 5. The next nursing physical assessment was completed on January 7, 2015 at 7:48 AM indicating that Patient 16's pain scale went down to 2.

During a concurrent interview with the IICN, confirmed and stated that the pain reassessment was not conducted sooner, as per hospital policy. There was no documented evidence that the pain reassessment was conducted 1 hour after Patient 16 received the Acetaminophen 650 mg orally for her headache with a scale of 5.

During a review of the hospital policy and procedure titled, "Pain Management," revised September 2013 indicated, "All health care professionals will assess each report of pain, including the nature of pain. The following characteristics ... should guide the pain assessment: Words to describe pain, Pain intensity on a 0-10 scale, 0 = no pain and 10 = worst pain imaginable ... Location of pain, Duration of pain (presence of persistent and/or breakthrough pain), Aggravating and alleviating factors ..." "A complete pain assessment will be done by nurses on admission and when pain is reported by the patient or recognized by the nurse ... Pain Management: Various options for pain control will be available to patients, including both drugs and noninvasive treatment ... Reassessment of pain following medication intervention will occur within 30 minutes of the administration of an IV (Intravenous) medication, within 30 minutes after the administration of an IM (Intramuscular) analgesic (pain medication) and 1 hour after the administration of any oral analgesic.

Based on interview and record review, the hospital failed to ensure the physician's telephone orders were authenticated with legible signatures, dates and times, as indicated in the hospital's policy (Medications - Telephone, Verbal, or Written Orders) for 4 of 21 ampled patients (Patient 15, 16, 17, and 19). This failure had the potential to contribute to medication errors which could increase the risk of patient harm due to use of medications that were not intended by the prescribing physician.

Findings:

1. A record review of Patient 15 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 8:30 AM. The record review indicated that Patient 15 was admitted on January 4, 2015 with the diagnosis of Diverticulitis (an inflammation of the colon) with rectal bleeding. A physician telephone order provided to a Registered Nurse (RN) on January 6, 2015 at 4:55 PM, for an anti-allergy and anti- nausea medication order, was not authenticated by the physician (62 days after the telephone order was received by the RN.) The IICN stated, "Missed and that the physician who provided the telephone order should have signed it."

2. A record review of Patient 16 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 9:30 AM. The record review indicated that Patient 15 was admitted on January 6, 2015 with the diagnosis of shortness of breath and bronchitis (inflammation of the mucus membrane of the bronchial tubes of the lungs.) There were multiple physician telephone orders were provided to the RN on the following dates: January 6, 2015 at 10:55 PM, January 7, 2015 at 12:55 AM, January 08, 2015 at 3:25 PM, January 9, 2015 at 10:35 AM, and January 10, 2015 at 11:30 AM, for multiple medication orders that contained an illegible physician signature with no date and time when the order was signed by the prescribing physician.

On January 6, 2015 at 10:55 AM, the physician order was signed with no date and time. The January 7, 2015 at 12:55 AM, the physician order was signed with no date and time. The January 08, 2015 at 3:25 PM, the physician order was signed 4 days after the order was provided to the RN with no time indicated when the telephone order was signed. The January 9, 2015 at 10:35 AM, physician order was signed 3 days after the order was provided to the RN with no time when signed. The January 10, 2015 at 11:30 AM, the physician order was signed 15 days after the order was provided to the RN with no indicated time when the telephone order was signed.

During the interview with the IICN on March 11, 2105 at 9:30 AM, the IICN confirmed and stated that the physician signatures were illegible, and were signed untimely, either with no date and or time when signed.

3. A record review of Patient 17 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 10:30 AM. The record review indicated that Patient 17 was admitted on January 14, 2015 with diagnosis of bronchitis (inflammation of the mucous membrane of the bronchial tubes of the lungs) and status post (s/p) fall. A physician telephone order provided to an RN on January 17, 2015 at 2:00 PM for pain management and to discontinue the foley (a urinary catheter inserted into the urinary tract for the purpose of draining the urine from the urinary bladder) catheter, was authenticated on February 2, 2015 with no time (16 days after the telephone order was received by the RN.) The IICN confirmed and stated that the telephone order was not signed timely and there was no time indicated when it was signed.

4. A record review of Patient 19 and a concurrent interview were conducted with the Informatics/Infection Control Nurse (IICN), on March 11, 2015 at 11:30 AM. The record review indicated that Patient 19 was admitted on February 3, 2015 for complaint of chest pain. A multiple physician telephone orders were provided to an RN for multiple medications on February 3, 2015 at 9:40 PM, February 4, 2015 at 9:55 AM, February 5, 2015 at 5:27 AM, February 5, 2015 at 9:23 AM, February 5, 2015 at 9:05 PM, and February 5, 2015 at 9:25 PM.

The physician orders for February 3, 2015 at 9:40 PM contained an illegible physician signature (9 days after the telephone order was provided) and did not include the time when the order was signed by the prescribing physician. The February 4, 2015 at 9:55 AM contained an illegible physician signature (8 days after the telephone order was provided) and did not include the time when the order was signed by the prescribing physician. The February 5, 2015 at 5:27 AM, February 5, 2015 at 9:23 AM, February 5, 2015 at 9:05 PM, and February 5, 2015 at 9:25 PM, contained an illegible physician signature (7 days after the telephone orders were provided) and did not include the time when the order was signed by the prescribing physician. The IICN confirmed and stated that the telephone orders were not signed timely and the physician's signatures were illegible.

During an interview with the hospital's Chief Nursing Officer/Chief Operating Officer (CNO/COO) on March 13, 2015 at 10:00 PM, the CNO/COO confirmed and stated that the physicians have been instructed and asked to signed telephone orders in a timely manner.

A record review was conducted on March 11, 2015 at various times, of the hospital policy and procedure titled, "Medications - telephone, verbal, or written orders, "revised 0n January 2012. The policy indicated, "The prescribing practitioner must sign the written record of the verbal/telephone order within 48 hours of giving the order."

Further record review of the hospital policy and procedure titled, "Medication Error Reduction Program," established March 5, 2015, Policy Guidelines: 10 - Telephone/Verbal Orders, indicated under number 9, "All telephone medication orders must be authenticated, timed, and dated by the Practitioner within 48 hours ..."