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Based on interview and record review it was determined the facility failed to ensure verbal orders were authenticated within forty-eight hours for (5) five of (30) thirty sampled patients ( Patients #16, 18, 17, 28, and 30).


The findings include:

1. Review of physician's orders for Patient #6 revealed a verbal order for a catheter flow x 1 for Peripherally Inserted Central Catheter (PICC)) line was obtained on 05/03/10, at 7:30 PM and was not authenticated by the ordering physician as of 06/01/10.

2. Review of physician's orders for Patient #28 revealed verbal orders dated 05/30/10, at 10:00 PM for (10) ten units of Novolin R ( Insulin) every six (6) hours only-do not give sliding scale insulin (SSI), discontinue SSI, continue the fingerstick blood sugars (FSBS) every six (6) hours. There was no documented evidence the order had been authenticated by the ordering physician as of 06/03/10. Further record review revealed a verbal order written on 05/31/10, at 11:20 AM to change the patient's Megace (appetite stimulant) to 400 milligram (mg) PO (by mouth) liquid daily. There was no documented evidence the verbal order had been authenticated by the ordering physician as of 06/03/10.

3. Review of physician's orders for Patient #18 revealed a verbal order dated 05/18/10, at 8:20 AM to notify the physician related to a decreased blood pressure, increased pulse, white blood count of 33.7. There was no documented evidence the verbal order had been authenticated by the ordering physician as of 06/03/10.

4. Review of physician's orders for Patient #30 revealed verbal orders on 06/01/10, at 9:00 AM to transfuse a six (6) pack FFP( Fresh Frozen Plasma), hold ASA( aspirin) and Plavix (Blood thinner), H&H ( hemoglobin and hematocrit) every four hours times four (4). There was no documented evidence the verbal orders had been authenticated by the ordering physician as of 06/03/10. Further record review revealed a verbal order dated 05/23/10, at 8:45 PM for a Stat (immediate) EKG (electrocardiogram), ABG (arterial blood gases), CBC (comprehensive blood count), CMP(comprehensive metabolic panel), DIG ( digoxin) Levels and Cardiac Enzymes and to hold all narcotics. There was no documented evidence the verbal orders were authenticated by the physician as of 06/03/10.

5. Review of physician's order for Patient #16 revealed verbal orders dated 05/27/10, at 7:00 AM, on 05/28/10 at 7:00 AM, and on 05/29/10 at 7:00 AM for the continuation of the indwelling catheter. There was no documented evidence the verbal orders had been authenticated by the ordering physician as of 06/03/10. Further record review revealed verbal orders on 05/28/10, at 7:50 AM for Zofran (anti-nausea) 4 mg IV (intravenous) every (4) four hours; and at 11:10 PM a verbal order to give Ativan ( antianxiety) 1 mg IV times one (1) dose now for agitation. There was no documented evidence the verbal order authenticated as of 06/03/10. On 05/29/10, at 9:15 AM a verbal order for stat (immediate) cardiac enzymes, consult cardiology, stat chest X-ray, Morphine ( narcotic pain medicine) 2 mg IV times 1 now, also on this date 05/29/10, at 12:10 PM a verbal order for Morphine 4 mg IV for unrelieved abdominal pain now times (1) one time was not authenticated by the ordering physician as of 06/03/10.

Interview on 06/03/10, at 3:00 PM with the President and CEO revealed the policy stated the physician was to sign the verbal order within forty-eight (48) hours of being received. She also stated the verbal orders were flagged daily with reminders for the physicians to sign verbal orders and this was the unit secretary's responsibility.

Review of the facility's policy on medical orders revealed verbal orders must be authenticated within (48) forty-eight hours of an order being given.

Based on interview and record review it was determined the facility failed to ensure medications given were appropriately signed for (3) three of (30) sampled patients (Patients #23, 27 and 30).


The findings include:

1. Record review for Patient # 30 revealed no documented evidence on the Medication Administration Record (MAR) for administration on 05/23/10, 05/24/10, 05/25/10, 05/26/10, 05/27/10, 05/28/10, 05/29/10, 05/31/10 and on 06/02/10 for Budesonide Suspension (inhalant) at 9:00 AM and 9:00 PM doses; and, Xopenex (inhaler/relax bronchial inflammation) these same dates at 9:00 AM and 9:00 PM.

2. Record review for Patient #27 revealed no documented evidence on the MAR for administration on 05/28/10 for Ipratropium Bromide (inhaler/nebulizer) at 8:00 AM, 2:00 PM and 8:00 PM. Xopenx (inhaler) at 8:00 AM, 2:00 PM and 8:00 PM and Symbicort (inhaler) at 9:00 AM and 9:00 PM. On 05/31/10, the record revealed no documentation for Ipratropium Bromide (inhaler/neb) at 8:00 AM, 2:00 PM and 8:00 PM, Xopex (inhaler) at 8:00 AM, 2:00 PM, and 8:00 PM; and, Symbicort (inhaler) at 9:00 AM and 9:00 PM. On 06/01/10, Budesonide Suspension (inhalant) was added to the patient's MARs with no documentation on 06/02/10, of the administration of the medications at the ordered times of 9:00 AM and 9:00 PM. Further review of the 06/02/10 MAR revealed no documentation for Symbicort (inhaler) being administered at ordered times 9:00 AM and 9:00 PM. Also Ipratatropium Bromide (inhaler/neb) and Xopenex (inhaler) no documentation of administration of ordered times of 8:00 AM, 2:00 PM, 8:00 PM, and 2:00 AM.

3. Record review for Patient #23 revealed no documentation on the MARs for administration on 05/27/10, 05/30/10 and 06/02/10 for Symbicort (inhaler) at 9:00 AM and 2100, Xopenx (inhaler) at 2:00 PM, 10:00 PM, 6:00 AM, Budesonide Suspension (inhalant)at 9:00 AM and 9:00 PM, and Spiriva ( inhaler) at 9:00 AM.

Interview on 06/03/10, at 2:00 PM with Respiratory Care Specialist revealed that all (MARs) Medication Administration Records should have documentation by the Respiratory Therapists that they have administered the treatment or medications with appropriate time, date and initials. He also stated that if a dose was missed it should be circled and the physician should be notified.

Review of the policy revealed Respiratory Therapists will deliver all MDI's (Metered dose inhaler) and hand held nebulizer treatments with documentation on the MAR and a progress note in the computer system.

Based on observation, interview and policy review it was determined the facility failed to ensure (1) one medication cart remained locked and attended while in the hallway. In addition,the facility failed to ensure a medication was administered for (1) one of (30) thirty sampled patients (Patient #20).

The findings include:

Patient #20 was admitted to the facility on 05/28/10 for rehabilitation of status post left below the knee amputation. Review of physicians orders for medications revealed Albuterol Sulfate (nebulizer treatment) was ordered on 05/28/10, to be administered every (4) four hours. Review of the Medication Administration Record (MAR) and Respiratory Therapy Notes revealed no documented evidence that the medication had been administered, as per physician's order.

Review of the facility's policy reveals that Respiratory Therapists would deliver all MDI's ( (Metered Dose Inhaler) and Hand Held Nebulizer with documentation on the MAR and progress note documented in the computer system.

Interview with the Respiratory Care Specialist on 06/03/10 at 2:23 PM, revealed the Unit Secretary did not transcribe Patient #20's 05/28/10 order for the Albuterol Sulfate and did not send the request for (RT) Respiratory Therapy to see the patient. Therefore, Patient #20 never received treatment by RT.

Observation on 06/01/10, at 3:10 PM on the satellite unit revealed a medication cart unlocked in the hallway.

Interview with the (DON) Director of Nursing on 06/10/10 at 3:10 PM revealed that all medication carts should be locked when unattended by the nursing staff.

Review of the facility's policy revealed the medication carts would be locked at all times with the following exception: "The nurse may take the cart inside the doorway to a patient's room and leave it unlocked while administering a medication so long as the cart is within view of the nurse at all times while it is unlocked."