HospitalInspections.org

Based on record reviews and interview, the facility failed to ensure telephone/verbal physician orders were dated and/or timed in 2 of 2 in-patient admissions for patient #1

Findings included:

Record review of patient #1's medical chart for her admission of 10/09/12 to 10/25/12 revealed 15 of 15 telephone/verbal orders that were not dated or timed by the authenticating physician.

Record review of patient #1's medical chart for her admission of 09/25/12 to 10/04/12 revealed 5 of 5 telephone/verbal orders that were not dated or timed by the authenticating physician.

Record review of the facility "Policy 3.140 entitled Health Clinical Policy: Verbal/Telephone Orders", revised August 2012, revealed the following statement: "Authenticate: The act of establishing that the order given is genuine as indicated by the Provider signature with the time and date of validation."

Interview on 03/13/13 at 10:30 AM with the facility Director Quality/Risk Management confirmed that physicians consistently dating and timing their verbal/telephone orders remains a problem at the facility.