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Based on interview and record review, the facility failed to ensure medical records were complete for 2 of 33 sampled patients (Patient 4 and Patient 5) when physician orders were incomplete or unsigned by the prescribing physician during an unplanned electronic medical record (eHR) downtime. These failures had the potential to prevent the health care team from providing accurate care.

Findings:

During an interview on 6/26/18 at 9:30 a.m., the Director of Integrated Quality (DIQ) stated an unplanned downtime with the eHR occurred on 5/14/18 at approximately 9:30 p.m. until 5/16/18 at 5:15 a.m. During this downtime, a backup system was implemented that included paper charting with handwritten notes and orders. These were then scanned and uploaded into the eHR when operation was resumed.

Patient 4 was admitted to the pediatric intensive care unit (PICU) from the emergency room with shortness of breath during the unplanned eHR downtime.

Review of Patient 4's eHR under the media tab reflected the scanned images of the backup paper chart used. Included in the scanned documents were preprinted physician admission orders specific for the PICU on a document titled "DTO SSR PED PICU GENERAL ADMISSION IP". The nine page form included a medication order section. In the medication area the following medications were ordered for Patient 4:

- ibuprofen (a non narcotic pain/ fever reducing medication) 100 mg/5 ml (100 milligrams in 5 milliliters - unit of measure defining the concentration) Oral suspension 10 mg/kg/dose (milligrams per kilogram per dose - units of measure defining milligrams of a medication multiplied by the patient's weight to determine the dose) = _____mg, oral Q6H (every 6 hours) PRN (as needed), Pain, Fever greater than 38 degrees Celsius/ 100.4 degrees Fahrenheit, pain scale 1-5 (10 point scale) Maximum dose 40 mg/kg/day. Not to be used in patients less than 6 months.
- acetaminophen pediatric suspension **Maintenance** 20 mg/kg/dose = ____mg, rectal, Q4H PRN, Pain, Fever greater than 38 degrees Celsius/ 100.4 degrees Fahrenheit, pain scale 1-5 (10 point scale) Maximum dose 60 mg/kg/day. Patients younger than 12: maximum 75 mg/kg/day, not to exceed 2600 mg/day, 650 mg/dose or 5 doses in 24 hours. Patients 12 and older: maximum 4 g (grams - a unit of measure)/day.
- ondansetron hydrochloride injection 0.1 mg/kg/dose = ______mg, Q6H, PRN nausea/vomiting, maximum of 4 mg.

During a concurrent eHR review for Patient 4 and interview with Licensed Nurse (LN) 1 on 6/27/18 at approximately 2:30 p.m., LN 1 stated the blanks with the actual calculated dose should have been completed by the prescribing physician.

Patient 5 was admitted to the general pediatric floor during the unplanned eHR downtime.

Review of Patient 5's eHR under the media tab reflected the scanned images of the backup paper chart used. Included in the scanned documents were handwritten orders written on 5/15/18 at 5:45 p.m. on the facility form titled "Physician Orders". No physician signature was observed at the ends of the orders nor any indication of the name of the prescribing physician. Additional review of the document reflected at the top of the order page "SIGN, DATE AND TIME ALL ORDER ENTRIES" and the bottom of the document "All orders require physician signature, date and time."

During a concurrent eHR review for Patient 5 and interview with LN 1 on 6/27/18 at approximately 2:45 p.m., LN 1 stated the orders should have been signed by the prescribing physician.

Review of the facility policy titled "Content and Documentation Policy for the Medical Record" last revised 3/2018, stipulated "..All orders regardless of entry mode must be signed, dated and timed..."

Review of the facility document titled "Medical Staff Rules" dated February 5, 2015, stipulated "...All orders for treatment shall be dated, noting the time ordered and signed by the physician responsible. All orders shall state the name, dosage, route and frequency of dispensing,..."

Based on interview and record review, the facility failed to ensure medical records were complete for 1 of 33 sampled patients (Patient 5) when telephone physician orders were unsigned during an unplanned electronic medical record (eHR) downtime. These failures had the potential to prevent the health care team from providing accurate care.

Findings:

During an interview on 6/26/18 at 9:30 a.m., the Director of Integrated Quality (DIQ) stated an unplanned downtime with the eHR occurred on 5/14/18 at approximately 9:30 p.m. until 5/16/18 at 5:15 a.m. During this downtime, a backup system was implemented that included paper charting with handwritten notes and orders. These were then scanned and uploaded into the eHR when operation was resumed.

Patient 5 was admitted to the general pediatric floor during the unplanned eHR downtime.

Included in the scanned documents were handwritten orders written on 5/15/18 at 5:45 p.m. on the facility form titled "Physician Orders".
Review of Patient 5's eHR under the media tab reflected the scanned images of the backup paper chart used. Included in the scanned documents were handwritten orders written on 5/15/18 at 1:00 p.m. on the facility form titled "Physician Orders". . No physician signature was observed authenticating a telephone order (orders taken by a licensed nurse verbally from a physician on the telephone) Additional review of the document reflected at the top of the order page "SIGN, DATE AND TIME ALL ORDER ENTRIES" and the bottom of the document "All orders require physician signature, date and time."

During a concurrent eHR review for Patient 5 and interview with Licensed Nurse (LN) 1 on 6/27/18 at approximately 2:45 p.m., LN 1 stated the orders should have been signed by the prescribing physician.

Review of the facility policy titled "Content and Documentation Policy for the Medical Record" last revised 3/2018, stipulated "..All orders regardless of entry mode must be signed, dated and timed... All acute hospital verbal orders must be signed, dated and timed with 48 hours by the ordering/supervising practioner, his/her designee, or any member of the medical team..."

Review of the facility document titled "Medical Staff Rules" dated February 5, 2015, stipulated "...All orders for treatment shall be dated, noting the time ordered and signed by the physician responsible. All orders shall state the name, dosage, route and frequency of dispensing,... Verbal Orders...All orders must be countersigned as soon as possible but within 48 hours by the prescribing physician or the physician assuming care in the prescriber's absence.""