HospitalInspections.org

Based on interview and review of documents including patient medical records, it was determined that the hospital failed to meet the requirements in CFR 482.23(c). Drugs shall be administered only upon the order of a practitioner who has been granted clinical privileges to write such orders. Verbal orders for drugs shall only be issued in emergency or unusual circumstances and shall be accepted only by a licensed nurse, pharmacist, or physician, and shall be immediately recorded and signed by the person receiving the order. The hospital's failure to require an order for medications places patients at risk for medication errors.
Findings included:
The patient required immediate interventions and therefore verbal orders were given by the physician to the registered nurse during the course of the patient care. On review of Patient #1's record, there were no written orders by the physician after the emergency care was provided. On further review of additional medical records, Patient #2 and #4 had medication orders charted without the corresponding physician order.