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Based on observation, staff interview, and review of medical records, bylaws, and hospital documents it was determined the hospital failed to ensure the Governing Body was effective and assumed responsibility for the conduct of the hospital staff. This resulted in the inability of the Governing Body to direct staff in the provision of patient care. It had the potential to impact all patients who received care at the hospital. Findings include:

on record review, hospital document review, staff bylaws review, and staff interviews

1. Refer to A - 0049 as it relates to the failure of the governing body to ensure medical staff were accountable to the Governing Body for the quality of patient care.

2. Refer to A - 0405 as it relates to the failure of hospital staff to administer medications as ordered by a physician.

3. Refer to A - 0407 as it relates to the failure of hospital staff including physicians' over-utilization verbal orders.

These systemic failures significantly impeded the ability of the hospital to provide safe patient care.

Based on record review, hospital document review, staff bylaws review, and staff interviews, it was determined the hospital failed to ensure its medical staff was accountable to the governing body for the quality of care provided to patients. This caused verbal orders to be over utilized. This resulted in controlled substances administered to 3 of 8 patients whose records were reviewed (Patients #1-3) without the order of a physician. Additionally, this had the potential to affect all patients receiving care in the hospital. Findings include:

1. Patient #1 was an 82 year old male who presented to the ED on 4/27/25 with the chief complaint of left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/01/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis.

Patient #1's record showed 5 verbal orders and one of unclear origin. Two verbal orders for conscious sedation were not signed by the ordering provider.

A review of Patient #1 's medical record revealed that two controlled substances, Hydromorphone and Midazolam, were administered on 4/29/25 at 11:22 AM by an RN. The record indicated a verbal order had been given by a physician; however, there was no signature or authentication from the physician.

The facility provided a medication cabinet override list, detailing instances where medications were retrieved from cabinets without a physician order. This list included Patient #1's RN accessed Hydromorphone and Midazolam via an override.

An interview was conducted with the listed ordering physician 5/21/25 at 2:40 PM, and Patient #1's medical record was reviewed in his presence. When asked whether he had ordered Midazolam and Hydromorphone for Patient #1, he denied providing any verbal orders and stated he had no communication with the dayshift nurses regarding Patient #1. He further stated he did not know how his name became associated with the medication orders.

An interview with the Director of Quality was conducted on 5/21/25 at 10:30 AM, during which Patient #1's medical record was reviewed. She confirmed the missing provider authentication. She stated she had investigated the orders and based on her investigation, suggested that the medication order may have been verbally given to a nightshift RN by the provider but was not entered into the EMR. The nightshift RN then relayed the verbal order to the dayshift RN, who subsequently retrieved the medication via override. The Director of Quality confirmed this practice was not permitted at the facility.

2. Patient #2 was an 82 year old male who presented to the ED on 4/21/25 with the chief complaint of acute bilateral embolism. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy.

Patient #2's medical records were reviewed. Patient #2's record showed 9 verbal orders. Additionally, 10 orders were not signed by a provider. The unsigned physician verbal orders included, but were not limited to midazolam, fentanyl, and lidocaine.

3. Patient #3 was a 67 year old female who presented to the ED on 4/27/25 with chief complaint of cardiac arrest. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received an EEG, CT scan, cardiac catheterization, and an MRI.

Patient #3's medical records were reviewed. Patient #3's record showed 38 verbal orders. Sixteen of the verbal orders were signed 5 days after the verbal order and one day after the patient had died. Additionally, 10 orders were not signed by a provider.

Patient#1, #2, and #3's medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the above verbal orders. She stated all verbal orders needed to be signed by the ordering provider.

The Director of Pharmacy was interviewed on 5/21/25 at 9:00 AM. When asked about the overutilization of verbal orders and medication overrides, where medications were accessed from cabinets without a physician-entered order in the hospital's EMR, he stated the issue had existed prior to his tenure and continued currently, due to procedural drift among physicians and nurses. He acknowledged the problem and had sent a memo outlining new procedures for verbal order usage; however, a new governing-body-approved policy had not been finalized at the time of the survey.

A hospital memo sent on 5/09/25 to staff and physicians outlined procedures for utilizing verbal orders, but no formal governing-body-approved policy was in place to ensure compliance.

The Chief of Staff was interviewed on 5/21/25 at 2:30 PM. When asked about his role, he stated that he runs meetings and helps coordinate hospital matters. When asked how he oversees physician quality of care throughout the hospital, he stated he does not oversee individual physicians directly. Regarding verbal order overutilization, he indicated that he had only been made aware of the issue the previous week, acknowledging that a memo had been sent but stating, "I may have been CC' d on it." There was no indication from the interview that the Chief of Staff had oversight of physician verbal order usage throughout the hospital.

Hospital staff bylaws were reviewed. Under the section titled "Chief of Staff" stated the Chief of Staff was responsible to the board, in conjunction with the Medical Executive Committee, for the quality and efficiency of clinical services and professional performance within the hospital. However, interviews revealed a lack of oversight in fulfilling this responsibility

The hospital Quality Director was interviewed on 5/21/25 at 3:15 PM. When asked who was appointed by the governing body to oversee medical staff conduct and quality of care, she stated that responsibility belonged to the Chief of Staff.

The hospital failed to ensure medical staff were accountable to the governing body regarding the overutilization of verbal orders.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure orders for the administration of medications were administered under the order of the practitioner or practitioners responsible for the patient's care for 3 of 7 patients (Patient #1, #2, #3) whose records were reviewed. Additionally, this had the potential to create unsafe medication administration with no physician or provider involvement. Findings include:

Patient medical records were reviewed. The medical records reviewed showed frequent usage of verbal orders with no authentication or follow up by the ordering provider making it unclear if the provider had ordered the medication. Examples included but were not limited to:

1. Patient #1 was an 82 year old male who presented to the ED on 4/27/25 with the chief complaint of left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/1/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis.

Patient #1's medical records were reviewed. Patient #1's record showed 4 verbal medication orders and one of unclear origin with no physician signature.

A review of Patient #1's medical record revealed that two controlled substances, Hydromorphone and Midazolam, were administered on 4/29/25, at 11:22 AM by an RN. The record indicated a verbal order had been given by a physician; however, there was no signature or authentication from the ordering physician.

The facility provided a medication cabinet override list, detailing instances where medications were retrieved from cabinets without a physician-entered order in the hospital's EMR. This list confirmed Patient #1's nurse accessed Hydromorphone and Midazolam via an override.

An interview was conducted with the ordering physician 5/21/25 at 2:40 PM, and Patient #1's medical record was reviewed in his presence. When asked whether he had ordered Midazolam and Hydromorphone for Patient #1, he denied providing any verbal orders and stated he had no communication with the dayshift nurses regarding Patient #1. He further stated he did not know how his name became associated with the medication orders.

2. Patient #2 was an 82 year old male who presented to the ED with chief complaint of acute bilateral embolism on 4/21/25. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy.

Patient #2's medical records were reviewed. Patient #2's record showed 4 verbal medication orders of with no physician signature. The unsigned physician verbal orders included, but were not limited to, midazolam, fentanyl, and lidocaine.

3. Patient #3 was a 67 year old female who presented to the ED with chief complaint of cardiac arrest on 4/27/25. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received EEG, CT scan, cardiac catheterization, and an MRI.

Patient #3's medical records were reviewed. Patient #3's record showed 4 verbal medication orders. The 4 verbal medication orders were not signed by a provider.

Patient#1, #2, and #3's medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the above verbal orders. She stated all verbal orders needed to be signed by the ordering provider.

It was unclear why the above patients' verbal orders were not authenticated by the ordering providers in a timely manner.

The hospital failed to ensure all orders were signed by the ordering provider.

Based on record review and staff interview, it was determined the facility failed to ensure the use of verbal orders was not a common practice and was not used for the convenience of the ordering practitioner. This failure directly impacted 3 of 7 patients (Patients #1, #2, and #3) whose written physician orders were reviewed, and had the potential to impact all patients receiving care at the facility. Additionally, this resulted in the administration of controlled substances to a patient without a medication order from a provider. This failure increased the risk of miscommunication or error resulting in an adverse patient event. The findings include:

Examples of frequent use of verbal physician orders included, but were not limited to:

Patient medical records were reviewed for Patients #1, #2, and #3. The medical records showed usage of frequent verbal orders with no authentication or follow up by the ordering provider. Examples included:

1. Patient #1 was an 82-year-old male who presented to the ED on 4/27/25 with the chief left knee pain. Patient #1 was subsequently admitted to the hospital and discharged on 5/1/25. Patient #1 received an ultrasound, CT scan, x-ray, and arthrocentesis.

Patient #1's medical records were reviewed. Patient #1's record showed 4 verbal medication orders and one of unclear origin with no physician signature.

2. Patient #2 was an 82-year-old male who presented to the ED with chief complaint of acute bilateral embolism on 4/21/25. Patient #2 was admitted to the hospital and discharged on 4/24/25. Patient #2 received an x-ray, ultrasound, CT scan, and thrombectomy.

Patient #2's medical records were reviewed. Patient #2's record showed 4 verbal medication orders of with no physician signature. The unsigned physician verbal orders included, but were not limited to midazolam, fentanyl, and lidocaine.

3. Patient #3 was a 67-year-old female who presented to the ED with chief complaint of cardiac arrest on 4/27/25. Patient #2 was admitted and died on 5/1/25. Patient #3 was intubated and received EEG, CT scan, cardiac catheterization, and an MRI.

Patient #3's medical records were reviewed. Patient #3's record showed 4 verbal medication orders. The 4 verbal medication orders were not signed by a provider.

Patient #1, #2 and #3's medical records were reviewed with the Patient Safety Coordinator on 5/21/25 at 1:30 PM. She confirmed the missing provider authentication of the verbal orders. She stated all verbal orders need to be signed by the ordering provider.

The Director of Pharmacy was interviewed 5/21/25 beginning at 9 AM. When asked, "Is the culture allowing convenience-based verbal orders?" he replied "Yes, historically. But that's no longer acceptable. We presented this to the medical executive team, and they approved new standards. Verbal orders must now follow strict criteria-emergency, off-hours, etc.-not convenience."

Through medical record review and staff interview, it was determined verbal orders were being over utilized for the convenience of providers. It was unclear why the above patients' verbal orders were not authenticated by the ordering providers in a timely manner.

The hospital failed to ensure verbal orders by physicians were not a common practice throughout the hospital.