HospitalInspections.org

Based on record review and interview, the facility failed to ensure that a physician-ordered medication is administered to one (#1) of 10 sample patients due to the omission of a physician telephone order.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted from 8-28-12 to 8-29-12 revealed no written orders for Narcan.

Review of the Administration Policy and Procedure#133: Orders including Verbal/Telephone Orders conducted on 8-28-12 included but not limited to: "Orders for procedures, treatments (including medications), activities and care or services shall be legibly or electronically written, signed, dated and timed at the time of writing or, if communicated orally in person or by telephone; signed, dated and timed by the ordering practitioner or another practitioner responsible for the patient's care within 48 hours of ordering."
"The Registered Nurse may accept, transcribe and implement verbal and telephone orders related to the administration of medications in accordance to Florida law, the level of licensure and scope of practice as approved by the medical staff and outlined in department policy and procedures."

Telephone interview with the Chemotherapy Unit - Kendall Campus [CTU-K] Staff RN I conducted on 8-28-12 at 110pm revealed that she took care of SP#1 on 7-24-12 when he became unresponsive and was transferred to the Hospital. She admitted receiving a telephone order for Narcan from SP#1's Physician. She stated that she "wrote the Narcan order on a sticky note and showed it to the Advanced Registered Nurse Practitioner [ARNP]. She told me it was not needed. I threw the paper. I did not write the order in the chart."

Interview with the Director of CTU-K conducted on 8-28-12 at 130pm confirmed no written orders for Narcan. She concurred that telephone orders from Physicians should be written in the patient's clinical records at all times.

Telephone interview with the CTU-K ARNP conducted on 8-28-12 at 210pm revealed that she does not recall any Narcan order for SP#1.

Interview with CTU-K Staff RN I conducted on 8-29-12 at 1230pm revealed that she clearly remembers telling the ARNP about the Narcan order and was told that it was not needed. She reiterated that the Physician order for Narcan was not written in SP#1's clinical record.

Interview with the CTU-K ARNP conducted on 8-29-12 at 1250pm revealed that she did not give any order on Narcan for SP#1 that day.

Based on record review and interview, the facility failed to ensure that all orders for drugs and biologicals are documented and signed by a practitioner who is responsible for the care of the patient, authorized to write orders by hospital policy and in accordance to State laws in one (#1) of 10 sample patients.

The findings include:

Clinical record review of Sample Patient (SP)#1 conducted from 8-28-12 to 8-29-12 revealed no written orders for Narcan.

Review of the Administration Policy and Procedure#133: Orders including Verbal/Telephone Orders conducted on 8-28-12 included but not limited to: "Orders for procedures, treatments (including medications), activities and care or services shall be legibly or electronically written, signed, dated and timed at the time of writing or, if communicated orally in person or by telephone; signed, dated and timed by the ordering practitioner or another practitioner responsible for the patient's care within 48 hours of ordering."
"The Registered Nurse may accept, transcribe and implement verbal and telephone orders related to the administration of medications in accordance to Florida law, the level of licensure and scope of practice as approved by the medical staff and outlined in department policy and procedures."

Telephone interview with the Chemotherapy Unit - Kendall Campus [CTU-K] Staff RN I conducted on 8-28-12 at 110pm revealed that she took care of SP#1 on 7-24-12 when he became unresponsive and was transferred to the Hospital. She admitted receiving a telephone order for Narcan from SP#1's Physician. She stated that she "wrote the Narcan order on a sticky note and showed it to the Advanced Registered Nurse Practitioner [ARNP]. She told me it was not needed. I threw the paper. I did not write the order in the chart."

Interview with the Director of CTU-K conducted on 8-28-12 at 130pm confirmed no written orders for Narcan. She concurred that telephone orders from Physicians should be written in the patient's clinical records at all times.

Telephone interview with the CTU-K ARNP conducted on 8-28-12 at 210pm revealed that she does not recall any Narcan order for SP#1.

Interview with CTU-K Staff RN I conducted on 8-29-12 at 1230pm revealed that she clearly remembers telling the ARNP about the Narcan order and was told that it was not needed. She reiterated that the Physician order for Narcan was not written in SP#1's clinical record.

Interview with the CTU-K ARNP conducted on 8-29-12 at 1250pm revealed that she did not give any order on Narcan for SP#1 that day.