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Based on medical record review and staff interview, it was determined that the facility failed to ensure that oral orders are used infrequently.

Findings include:

1. A review of physician orders in eight Medical Records (#9, #11, #12, #13, #14, #19,
#23 and #26), revealed the following:

a. Seven out of fifteen physician orders in Medical Record #9 were oral orders.

b. Two out of four physician orders in Medical Record #11 were oral orders.

c. Four out of nine physician orders in Medical Record #12 were oral orders.

d. Three out of six physician orders in Medical Record #13 were oral orders.

e. Eleven out of twenty six physician orders in Medical Record #14 were oral orders.

f. Four out of ten physician orders in Medical Record #19 were oral orders.

g. Three out of three physician orders in Medical Record #23 were oral orders.

h. Six out of eighteen physician orders in Medical Record #26 were oral orders.

2. The above finding were confirmed by Staff #1 and Staff #5.

Based on staff interview, review of the facility's medical staff rules and regulations, and medical record review on the day of survey June 10, 2011, it was determined that the facility failed to ensure that all verbal orders are authenticated within 48 hours.

Findings include:

Reference: The facility's 'Medical Staff Rules and Regulations' Page 9 of 18, C. General Conduct of Care number 2 states, "...All oral orders shall be authenticated as soon as possible or within 48 hours."

1. A review of eight Medical Records (#9, #11, #12, #13, #14, #19, #23, and #26) of admitted patients, revealed that the use of oral orders were not authenticated as soon as possible or within 48 hours as per facility 'Medical Staff Rules and Regulations.'

a. Seven out of fifteen physician orders in Medical Record #9 were verbal orders. All seven verbal orders failed to reflect the time the physician authenticated the order. One of the seven oral orders failed to include the physician's signature. All seven oral orders failed to be authenticated for a period of time greater than 30 days.

b. One out of four physician orders in Medical Record #11 were oral orders. One oral order failed to reflect the physician signature and the time the physician authenticated the order. The oral order failed to be authenticated for a period of time greater than 40 days.

c. Two out of nine physician orders in Medical Record #12 were oral orders. The two oral orders failed to reflect the time the physician authenticated the order. Both oral orders failed to be authenticated for a period of time greater than 30 days.

d. Three out of six physician orders in Medical Record #13 were oral orders. The three oral orders failed to reflect the time the physician authenticated the order. All three oral orders failed to be authenticated for a period of time greater than 30 days.

e. Eleven out of twenty six physician orders in Medical Record #14 were oral orders. The eleven oral orders failed to reflect the time the physician authenticated the order. Six of the eleven oral orders failed to include the physician's signature. All eleven oral orders failed to be authenticated for a period of time greater than 30 days.

f. Four out of ten physician orders in Medical Record #19 were oral orders. Two of the four oral orders failed to include a date and time of when the physician authenticated the oral order.

g. Three out of three physician orders in Medical Record #23 were oral orders. The three oral orders failed to reflect the physician's signature and the time the physician authenticated the order. All three oral orders failed to be authenticated for a period of time greater than 30 days.

h. Six out of eighteen physician orders in Medical Record #26 were oral orders. Five of the six oral orders failed to reflect the time the physician authenticated the order. All six oral orders failed to be authenticated for a period of time greater than 4 days.

2. There was no evidence that the facility ensured that all physician oral orders are authenticated as soon as possible or within 48 hours as per the Medical Staff Rules and Regulations stated above.

3. The above findings were confirmed by Staff #1.