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LAUREL RIDGE TREATMENT CENTER
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
Based on record review and interview, the facility to ensure physicians promptly authenticated, dated, and timed verbal/telephone orders.
Findings were:
Two of two verbal orders for Patient #1 were not authenticated by the ordering physician.
? Physician Admission Orders dated 1-24-12 that were marked " TORB " had a physician signature but no date or time indicated.
? On 1-24-12 at 2222 the following order: " 1) Singular 5 mg PO q day-asthma 2) Depakote 500 mg PO BID-mood, 3) Seroquel 200 mg q HS-mood, 4) Prozac 40 mg PO q AM-mood, 5) Concerta 72 mg PO q AM-ADHD, 6) Vistaril 50 mg PO q 6 hours PRN-anxiety/agitation. TORB " had no physician signature, date, or time.
The lack of documented monitoring of the patient at pre-determined intervals was confirmed in an interview on 4-2-12 with Risk Manager and Chief Nursing Officer.