HospitalInspections.org

Based on medical record review, policy review, and staff interview the facility failed to ensure all verbal or telephone orders were authenticated by the physician within 48 hours.

Findings were:

Review of patient medical record for patient #1 on 4/13/17 revealed the following telephone orders were not authenticated by the physician:
* 3/20/17: 1 order
* 3/21/17: 1 order
* 3/30/17: 1 order
* 3/31/17: 2 orders
* 4/1/17: 1 order
* 4/2/17: 1 order
* 4/5/17: 3 orders
* 4/7/17: 1 order

Facility policy titled "Timeliness Texas; Number: HIM-01.05" states in part "Physician/LIP orders are to be written and signed by the Physician/LIP. Telephone and verbal orders are taken by a licensed nurse and authenticated by the ordering Physician/LIP within 96 hours."

Facility document titled "Medical Staff Bylaws, adopted 4/4/16" states in part "All orders for treatment must be in writing. Orders dictated by telephone shall be signed by the person to who dictated with the name of the ordering medical staff member and then signed by the person to who dictated. Within forty-eight (48) hours after the order, the ordering medical staff member shall date and sign the orders."

In an interview with the Administrator and the Director of Nursing both acknowledged the discrepancy in the wording of the 2 documents and both acknowledged the facility policy was not per Texas regulations for verbal or telephone physician orders to be authenticated within 48 hours.