HospitalInspections.org

Based on document review and interview, the critical access hospital (CAH) failed to ensure telephone orders (TO) and verbal orders (VO) were timed and dated by the prescribing physician in a timely manner for 5 of 20 patient (P1, P2, P3, P4, P5) records reviewed who had been in-patients receiving medical care in the CAH.

Findings include:

P1 was admitted to the CAH on 2/26/13 with discharge on 3/8/13, and five (5) telephone orders had been signed by physician but were not dated and timed.

P2 was admitted to the CAH on 6/7/13 with discharge on 6/11/13, and one (1) telephone order had been signed by physician but were not dated and timed.

P3 was admitted to the CAH on 2/20/13 with discharge on 2/21/13. One (1) verbal order had not been timed and dated when the physician signed orders.

P4 was admitted to the CAH on 1/13/13 with discharge on 1/15/13. Two (2) telephone orders had not been date and time when the physician signed the orders.

P5 was admitted to the CAH on 2/19/13 with discharge on 2/21/13 . One (1) verbal order not been dated or timed when the physician signed the orders.

In review of the CAH's policy Verbal/Written Orders-General Practices Pharmacy Services Policy #03.3-03 reviewed 7/2011, under Procedure: 3 the following was included: "The prescribing practitioner must sign the written record of the verbal/telephone order within 24 hours of giving the order." The policy did not address that the physician must date and time the order upon submitting signature. Upon request, no other policy was provided to address this issue.

On 9/12/13 at 10:45 a.m., the executive director of patient services (EDPS) was interviewed. She indicated the policy reviewed was the only facility policy on verbal/telephone orders. The EDPS also verified physicians were to sign the orders within 24 hours, and confirmed theCAH was having a problem with physicians dating and timing orders when authenticating with their signatures.