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KAU HOSPITAL
No Description Available
Tag No.: C0297
Based on closed record reviews and staff interview, the facility did not ensure all drugs, biologicals, and intravenous medications were administered in accordance with written and signed orders by the physician for 3 of 13 closed records reviewed.
Findings include:
1) Closed record review noted a patient admitted to the facility on 2/22/11 with diagnoses of fracture left pelvis, cervix cancer, and anemia. Review of verbal order dated "2/23/11 at 1155 May give Dilaudid 4 mg SIVP now - vo [Dr. ]". There was no signature of the physician ordering the medication. Interview with the Charge Nurse on 5/16/12 at 1:35 P.M. and concurrent review of the record (both hard copy and electronic medical record) confirmed the physician did not sign the verbal order. According to the Charge Nurse, verbal orders should be signed as soon as possible.
2) A closed record for a patient admitted on 5/19/10 and discharged on 5/21/10 found a Physician's Order dated 5/19/10 that was not signed by the physician. The physician is no longer employed at this hospital.
3) Closed record review for a patient admitted on 5/17/10 and discharged on 5/21/10 had verbal orders dated 5/19/10 that were not signed by the physician. The physician is no longer employed at this hospital.
No Description Available
Tag No.: C0304
Based on closed record reviews and staff interview, the facility did not ensure for each patient receiving health care services, the facility maintains a record that includes, a brief summary of the episode, disposition, and instructions to the patient for one of 13 closed records reviewed.
Findings include:
Closed record review done on 5/16/12 noted a patient admitted to the facility on 6/6/11 with diagnoses including dehydration, urinary tract infection, and failure to thrive. The patient was discharged to long term care on 6/9/11. Further review of the record could not find a discharge summary. Interview with the Charge Nurse on 5/16/12 at 11:00 A.M. and concurrent review of the closed record confirmed there was no discharge summary. The Charge Nurse stated that a discharge summary should have been completed.