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Based on document review and interview, Nursing Services failed to document verbal orders from 3 (Physiciain #13, #14, and #15) of 3 physicians for moderate sedation medications in the Radiology Department in 3 (Patient #2, #3, and #4) of 3 medical records reviewed. Also, the hospital failed to ensure physicians signed verbal orders for sedation medications according to the facility's Verbal Order Policy.

Findings:

Patient #2
Patient #2 was a 53-year-old female scheduled for a CT-guided intra-abdominal abscess drainage in the Radiology Department by Physician #13 on 9/09/2024. A review of the medical record revealed Registered Nurse (RN) Staff #8 was the assigned nurse for the procedure.

A review of the medication orders revealed that Versed (Midazolam, a sedative medication) 2 milligrams/milliliter (mg)/(ml) and Fentanyl (an opioid pain medication) 100mcg/2ml were removed from the medication cabinet on 9/09/2025 at 3:57 PM by RN #8. The administration instructions read, "RN #8, cabinet override and Medication Comments: RN #8, cabinet override". There was no ordering or authorizing physician on the medication order.

A review of the Medication Administration record for Midazolam (Versed) was as follows:

"Ordering Provider: Physician #13, Ordered on: 09/09/2024 at 4:33 PM, Frequency: Intra-op PRN (as needed)
Performed 9/09/2024 at 4:29 PM, 1 mg Intravenously (IV) by RN #8
Performed 9/09/2024 at 4:33 PM, 0.5 mg IV by RN #8
Performed 9/09/2024 at 4:36 PM, 0.5 mg IV by RN #8
Performed 9/09/2024 at 4:40 PM, 0.5 mg IV by RN #8.


A review of the Medication Administration record for Fentanyl was as follows:

"Ordering Provider: Physician #13, Ordered on: 09/09/2024 at 4:33 PM, Frequency: Intra-op PRN
Performed 9/09/2024 at 4:33 PM, 50 mcg (micrograms) IV by RN #8
Performed 9/09/2024 at 4:36 PM, 25mcg IV by RN #8
Performed 9/09/2024 at 4:37 PM, 25mcg IV by RN #8
Performed 9/09/2024 at 4:40 PM, 50 mcg IV by RN #8."


Patient #3
Patient #3 was a 63-year-old male scheduled for a CT Biopsy of a left lower lung nodule on 8/12/2025 by Physician #15. A review of the medical record revealed RN #16 was the assigned nurse for the procedure on 8/12/2025.

A review of the medication orders revealed that RN #16 wrote an order on 8/12/2025 at 8:35 AM that read,

"Fentanyl IV Intra-op PRN and Versed IV Intra-op PRN".

A review of the Medication Administration record for Versed was as follows:
"8/12/2025 at 8:28 AM 1mg IV administered by RN #16,
8/12/2025 at 8:34 AM 0.5mg IV administered by RN #16,
8/12/2025 at 8:42 AM 0.5mg IV administered by RN #16."

A review of the Medication Administration record for Fentanyl was as follows:
"8/12/2025 at 8:28 AM 50 mcg IV administered by RN #16,
8/12/2025 at 8:34 AM 25mcg IV administered by RN #16,
8/12/2025 at 8:42 AM 25mcg IV administered by RN #16."

An interview was conducted with RN #7 on 8/12/2025 after 2:00 PM. RN #7 confirmed that Physician #15 did not enter the orders for the Versed and Fentanyl for the procedure, and that RN #16 did not write any verbal orders for the moderate sedation medications administered to Patient #3 during the procedure.


Patient #4
Patient #4 was a 90-year-old male scheduled for an Arteriogram on 8/12/2025 by Physician #14. A review of the medical record revealed RN #9 was the assigned nurse for the procedure.

A review of the medication orders revealed that RN #9 wrote an order on 8/12/2025 at 8:21 AM that read, "Fentanyl IV Intra-op PRN and Versed IV Intra-op PRN".

A review of the Medication Administration record for Versed was as follows:
"8/12/2025 at 8:21 AM 1mg IV administered by RN #9."

A review of the Medication Administration record for Fentanyl was as follows:
"8/12/2025 at 8:21 AM 50 mcg IV administered by RN #9."


An interview was conducted with RN #7 on 8/12/2025 after 2:00 PM. RN #7 confirmed that Physician #14 did not enter the orders for the Versed and Fentanyl for the procedure, and that RN #9 did not write any verbal orders for the moderate sedation medications administered to Patient #4 during the procedure.


An interview was conducted with RN Staff #8 on 8/12/2025 after 2:00 PM. RN Staff #8 was asked who gave the sedation medication orders for the intervention radiology procedures. RN Staff #8 stated that the physician performing the procedure gave verbal orders during the procedure. RN #8 was asked if the physician put any of the orders in the computer. RN #8 stated, "We put the order in that says 'Intra-op PRN' ordered by the physician, but there is no specific dose entered before the start of the procedure. The physician will tell us the dose to give during the procedure." RN #8 was asked if she put in the verbal orders for the sedation medications during the procedure. RN #8 confirmed she did not enter any verbal orders in the computer for any of the medications that she administered during the procedure.

An interview was conducted with Staff #1 on 8/12/2025 after 2:00 PM. RN Staff #1 was asked if the physicians performing the procedures did not enter the moderate sedation orders, who signed the orders for the sedation drugs. RN Staff #1 stated, "It should be the physician who is doing the procedure". RN Staff #1 was asked if verbal orders do not get entered, how does the physician know he had to sign the order? "Staff #1 replied that he would not know. There would not be an outstanding order for him to sign.


RN Staff #1 confirmed there were no signed physician orders or verbal orders for the moderate sedation medications administered by the nursing staff for 3 (Patient #2, #3, and #4) of 3 patient medical records reviewed.


A review of the hospital policy titled, "Verbal/Telephone Orders" Number 3.140, with a revised/reviewed date of 3/24 was as follows:

" ...II. OBJECTIVE/S: This policy delineates the CHRISTUS Health Associates that are qualified to receive verbal/telephone orders, the individuals from which verbal/telephone orders may be received, and the process for recording, transcribing, transmitting, and authenticating verbal/telephone orders with the goal-of maximizing patient safety.

III. POLICY STATEMENT: CHRISTUS Health IS committed to the promotion of patient safety and compliance with regulatory requirements,

IV. DEFINITIONS:
A. Verbal Order: An order which is given face-to-face in an urgent. or emergent situation from a
licensed approved member of the Medical Staff to a qualified CHRISTUS associate ...

V. PROCESS:
A. Verbal Orders:

1. In the Interest of patient safety and to minimize errors, Providers should write/enter their orders, not give verbal orders, when present and able to do so themselves. The exception is during urgent or emergent situations when a Provider will verbally relay an order to a qualified associate in real-time, face-to-face, Providers should subsequently enter their orders in the computer system once they are able to access a computer.

2. All verbal orders must be documented in the medical record.

3. When using CPOE, the appropriate individual will access the patient within the EHR, enter the ordering provider, enter the order source as VERBAL, and then enter the order as directed by the provider.
a) The order is then verbally read back to the provider. Any alerts/rules/reminders that are presented during the order entry process are read to the provider and the provider's response to the alerts/rules/reminders are entered into the computer.
b) Once the order is confirmed by the provider, the order is filed in the EHR and is considered to have been 'read back'.
c) The order may then be carried out or sent to the appropriate department for validation/processing,.."