HospitalInspections.org

Based on record review and interview the facility failed to follow to ensure that verbal/telephone orders were authenticated in a timely manner and according to facility policy.

Findings:

During medical record review for Patient #1 it was revealed that on 2/22/11 at 9 AM a telephone order for "consent for right patella incision and drainage" and "xylocaine 1% with epinephrine" was written by the Registered Nurse. There was no physician's signature authenticating the order.
Interview with the Risk Manager on 3/3/11 at 2:50 PM stated that she checked the computer system and no electronic authentication had been done by the physician.
The policy provided by the facility titled, "Physician Orders-Phone/Verbal/Written" states that physician orders may be received verbally, by telephone or written by any licensed professional including nurses, registered dieticians, medical social workers and pharmacists. The policy also states that "a physician must sign, date and time these orders within 48 hours."