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Tag No.: A0457
Based on record review, hospital policy, and interview, the hospital failed to ensure that verbal orders were authenticated by a practitioner in accordance with hospital policy and State law for 12 of 12 sampled patients (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12). This deficient practice has the potential to affect early identification and correction of verbal orders. The findings are:
A. Review of Patient #1's medical record revealed that 21 out of 44 physician order entries were not authenticated by a physician in a timely manner.
B. Review of Patient #2's medical record revealed that 2 out of 2 physician order entries were not authenticated by a physician in a timely manner.
C. Review of Patient #3's medical record revealed that 2 out of 3 physician order entries were not authenticated by a physician in a timely manner.
D. Review of Patient #4's medical record revealed that 8 out of 8 physician order entries were not authenticated by a physician.
E. Review of Patient #5's medical record revealed that 1 out of 5 physician order entries were not authenticated by a physician in a timely manner.
F. Review of Patient #6's medical record revealed that 3 out of 11 physician order entries were not authenticated by a physician in a timely manner.
G. Review of Patient #7's medical record revealed that 4 out of 12 physician order entries were not authenticated by a physician in a timely manner.
H. Review of Patient #8's medical record revealed that 2 out of 11 physician order entries were not authenticated by a physician in a timely manner.
I. Review of Patient #9's medical record revealed that 6 out of 8 physician order entries were not authenticated by a physician in a timely manner.
J. Review of Patient #10's medical record revealed that 4 out of 8 physician order entries were not authenticated by a physician in a timely manner.
K. Review of Patient #11's medical record revealed that 1 out of 4 physician order entries were not authenticated by a physician in a timely manner.
L. Review of Patient #12's medical record revealed that 5 out of 9 physician order entries were not authenticated by a physician in a timely manner.
M. Review of the facility's policy and procedure titled "Verbal Orders," approved on 06/09/11, indicated, "All Verbal Orders shall be authenticated by the ordering practitioner within 72 hours of giving the Verbal Order..." The stated purpose of the policy was the following: "To ensure proper and timely documentation and authentication of verbal orders. To enhance patient safety by reducing use of verbal/telephone orders due to high potential for errors and misinterpretation of orders."
N. On 12/14/11 at 11:10 am, during interview, the Supervisor of Medical Records confirmed that the physician order entries are not authenticated within the 72 hours in accordance with hospital policy.