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Based on observation, interview, and record review, the hospital failed to ensure the medical records for two of 18 sampled patients (Patients 35 and 36) accurately reflected the care provided to the patients. The nursing staff failed to document a verbal order for the dosage of a medication for Patient 35. The Cardiac Cath Lab staff failed to document a physician's verbal order for a procedure for Patient 36. These failures created a potential risk for medication errors and wrong procedures for the patients.

Findings:

1. Review of Patient 35's medical record was initiated on 10/7/15. The patient was admitted to the hospital on 10/4/15.

Review of a physician's order dated 10/4/15 at 0836 hours, showed an order for metoprolol (a medication used to treat high blood pressure) 25 mg twice a day.

However, review of the MAR showed Patient 35 received metoprolol 12.5 mg on 10/6/15 at 0936 hours.

Further review of Patient 35's medical record failed to show a physician's order to administer metoprolol 12.5 mg on 10/6/15 at 0936 hours.

During an interview and concurrent medical record review on 10/7/15 at 0845 hours, RN E confirmed the finding.

During an interview on 10/8/15 at 1440 hours, the CNO stated the nursing staff communicated with the Nurse Practitioner to obtain an order to administer metoprolol 12.5 mg dose for Patient 35; however, the nurse failed to document the order in Patient 35's medical record.


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2. The hospital's P&P titled Orders reviewed 9/13 showed verbal orders are orders given when the physician/allied health professional is present. Verbal orders are only taken during emergent situations. The P&P also showed the staff should repeat the order back to the physician/allied health professional to clarify the order before implementing; verbal orders are processed immediately and entered into the electronic medical record.

On 10/7/15 at 0847 hours, during an observation of an emergency Cardiac Cath Lab procedure, the circulating RN initiated the time out, using an informed consent signed by Patient 36.

Review of Patient 36's Verification of Consent and Authorization for Surgery, Obstetrical, Special Diagnostic, or Therapeutic Procedures form showed the procedures included a "Right and Left Heart Catheterization with angioplasty, Left ventriculogram and possible Percutaneous Intervention under Moderate Sedation, Possible Emergency Coronary Artery Bypass Graft Surgery, under General Surgery."

On 10/8/15 at 0843 hours, Patient 36's medical record review was conducted with the Manager Critical Care Services and showed the patient had a cardiac procedure performed on 10/7/15 from 0839 to 0959 hours.

After reviewing Patient 36's medical record, the Manager Critical Care Services stated there was no documented evidence to show a physician's order for a Right and Left Heart Catheterization.

On 10/8/15 at 1155 hours, during an interview, RN B stated Patient 36 was transferred from another general acute care hospital. The RN stated he received a verbal order from Patient 36's treating physician for a Right and Left Heart Catheterization; however, he did not have time to enter the order because it was an emergency case.