HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to ensure nursing services only performed procedures with a signed physician order for one (Patient #1) of four sampled patients. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

The findings include:

On 9/9/10, clinical record review revealed Patient #1 presented to the Emergency Department on 8/12/10. Documentation shows, at 9:11 p.m., the patient had a Foley catheter placed by nursing staff. Review of the record shows there is no physician order for Foley catheter placement.

Interview with the nurse revealed she had informed the physician who may have thought she had written the order. Lack of a physician order was confirmed with hospital staff. The Foley catheter was removed on 8/12/10 at 10:30 p.m without a physician order.