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Based on documentation review and interviews, the hospital failed to ensure verbal/telephone orders for 4 of 9 patients (P1, P2, P3, and P4) were reviewed and signed by the ordering physician according to Federal and State laws and hospital policy and procedure. Findings include:

Review of the hospital policy and procedure for Verbal and Telephone Orders, revised on 12/2012, revealed "6. All verbal and telephone orders must be electronically signed by the ordering provider within 48 hours."
An interview was conducted with the director of nursing on 4/18/14 at 10:12 a.m. and she stated the hospital had both hard copy charts with hand written physician orders and electronic charts with physician orders. Some patients had orders written, reviewed, and signed on paper and some patients had orders written, reviewed and signed electronically.

An interview with the staff development coordinator was conducted on 4/21/14 at 10:15 a.m. and she verified physicians who give verbal/telephone orders are to review and sign those orders within 48 hours according to the hospital policy and procedure.A review of the medical record for P1 noted he had hospital stays of 1/27/14 through 4/17/14 on medical and behavioral units. A nurse received a verbal/telephone order on 1/31/14 at 1640 (4:40 p.m.) to increase Depakote to 1000 milligrams oral at supper, switch Namenda to 14 milligrams extended release in the morning, Buspar 5 milligrams oral three times a day and to check a Depakote level on Monday 2/3/14. The physician review and sign was noted to be on 2/3/14 at 1400 (2:00 p.m.). On 2/7/14 at 2056 (8:56 p.m.) a nurse received a verbal/telephone order from a physician for Zyprexa 5 milligrams oral or intramuscular now. Documentation shows this was reviewed and signed by the physician on 2/10/14 at 1010 (10:10 a.m.). On 2/7/14 at 2238 (10:38 p.m.) a nurse received a verbal/telephone order for Zyprexa 10 milligrams oral or intramuscular and may hold for intramuscular injection if the patient refuses the oral dose. This order was noted to be reviewed and signed by the physician on 2/10/14 at 1010 (10:10 a.m.). On 2/13/14 at 2112 (9:12 p.m.) a nurse received a verbal/telephone order from a physician for "may hold patient for IM Vistaril for agitation" which was reviewed and signed by the physician on 3/31/14 at 1100 (11:00 a.m.). On 2/18/14 at 1555 a nurse received a verbal/telephone order to transfer the patient to BHU (behavioral health unit), same meds as before, D5 1/2 normal saline at 150 milliliters an hour, same diet mechanical soft with ground moist meat additional 6 grams of protein, 1 can of ensure with each meal, no coffee, basic metabolism profile in the morning. The physician reviewed and signed the orders on 3/24/14 at 830 (8:30 a.m.) The physicians failed to review and sign these verbal/telephone orders within 48 hours according to the hospital policy and procedure. A review of the medical record for P2 noted she had a hospital stay from 2/26/14 through 3/12/14 on the behavioral health unit. A review of the medication orders and medication record a physician ordered and nurse received revealed P2 had three verbal/telephone orders received by a nurse but not reviewed and signed by the physician within the 48 hours according to the hospital policy and procedure. On 2/27/14 at 17:53 (5:53 p.m.) a nurse received a verbal/telephone order from the physician for an as needed lap buddy for safety. This order was not reviewed and signed by the ordering physician in the chart, but was signed electronically on 3/2/14 at 18:51 (6:51 p.m.) by the ordering physician. On 2/27/14 at 2042 (8:42 p.m.) a nurse received a verbal/telephone order for Zyprexa 5 milligrams intramuscular as needed for one time for agitation. The physician reviewed and signed the order on 3/3/14 at 1100 (11:00 a.m.). The physician electronically signed the order on 3/3/14 at 18:51 (6:51 p.m.). On 2/27/14 at 2042 (8:42 p.m.) a nurse On 2/27/14 at 2042 (8:42 p.m.) a nurse received a verbal/telephone order from the physician allowing staff to hold the patient for an injection. The physician reviewed and signed this order on 3/12/14 at 1100 (11:00 a.m.) The physician failed to review and cosign the orders within the 48 hours allowed according to the hospital policy and procedure.A medical record review for P3 noted she had a hospital stay from 2/12/14 through 2/20/14 on the behavioral health unit. On 2/15/14 at 1055 (10:55 a.m.) a nurse received a verbal/telephone order from the physician to increase Remeron to 15 milligrams orally at bedtime, a verbal/telephone order to change Namenda to extended release 14 milligrams at start on 2/16/14 morning, and a verbal/telephone order to increase Tenex to 0.5 milligrams orally in the morning and 1 milligrams at bedtime. These medication order changes were reviewed and cosigned by the physician on 2/18/14 at 1000 (10:00 a.m.). The physician failed to review and cosign the orders within 48 hours as according to the hospital policy and procedure.A medical record review for P4 noted she had a hospital stay beginning 3/6/14. On 3/21/14 at 1100 (11:00 a.m.) a nurse received a verbal/telephone order to increase Neurontin to 100 milligrams three times a day orally to be given with meals. The physician reviewed and signed the order on 3/24/14 at 100 (1:00 p.m.). On 3/17/14 at 0830 (8:30 a.m.) a nurse received a verbal/telephone order from the physician to change the Coumadin dose to 1 milligrams daily. The physician reviewed and signed this order electronically on 3/23/14 at 1035 (10:35 a.m.). On 3/7/14 at 1330 (1:30 p.m.) a nurse received a verbal/telephone order from a physician to change Melatonin to 3 milligrams orally at bedtime. This order was reviewed and signed by the physician on 3/10/14 at 1100 (11:00 a.m.). On 3/6/14 at 1330 (1:30 p.m.) a nurse received a verbal/telephone order from the physician to do blood cultures. The physician reviewed and signed the order on 3/10/14 at 0840 (8:40 a.m.) On 3/7/14 at 1300 (1:00 p.m.) a nurse received a verbal/telephone order to obtained a sedimentation rate and CRP. The physician electronically reviewed and signed the order on 3/10/14 at 1104 (11:04 a.m.). The physicians failed to review and sign the orders within 48 hours as according to the hospital policy and procedure.