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Based on MR review, Medical Staff Rules and Regulations, and staff interview (Staff B), this facility failed to ensure that telephone/verbal (TO/VO) orders are properly authenticated with signature, date, and time within a 48-hour period of being written in 3 out of 8 out of a total of 10 MRs reviewed (Pt.s #1, 3, and 4). Failure to have properly authenticated TO/VO has the potential to affect all patients receiving care in this facility, including the 6 patients present during the survey.

Findings include:


The Medical Staff Rules and Regulations (R/Rs), dated 10/3/2013, were reviewed on 10/21/2013 at 2:30 p.m. On page 6 the R/Rs state, "Verbal and telephone orders will be signed, dated, and timed by the Practitioner within forty-eight (48) hours of receipt."

A MR review was conducted on 10/21/2013 at 10:40 a.m. on Pt. #1's closed OB record accompanied by HIM Mgr B. Pt. #1 was admitted to the facility on 10/19/2013 for childbirth. The Delivery and Postpartum pre-printed orders were noted and signed off by nursing staff at 6:22 a.m. however the provider failed to sign, date, or time the order set. Mgr B confirmed these findings at the time of the MR review stating the order set should have been signed.

A MR review was conducted on 10/21/2013 at 11:46 a.m. on Pt. #3's closed MR accompanied by HIM Mgr B. Pt. #3 was admitted to the facility through the ED on 10/14/2013 with delirium (confusion) secondary to illness and diverticulitis (inflammation in the bowel). The ED record, which contains orders for x-rays and laboratory tests was not signed, dated, or timed by the provider. The laboratory tests were written by the RN without a date and time of writing the orders, and without provider authentication within 48 hours.

There are TO's on 10/16/2013 and 10/17/2013 that are not authenticated by a provider within 48 hours. Mgr B confirmed these findings at the time of the MR review.

A MR review was conducted on 10/21/2013 at 1:15 p.m. on Pt. #4's closed MR accompanied by HIM Mgr B. Pt. #4 was admitted to the facility on 10/15/2013 for pneumonia. Between 10/16 and 10/17/2013 there are 4 telephone orders that are not authenticated by a provider within 48 hours. Mgr B confirmed these findings at the time of the MR review.

In an interview with Mgr B during the MR reviews regarding changes made since the initial recertification regarding TO's, Mgr B stated the staff are responsible for flagging TOs so they can clearly be seen by the provider for authentication. It was noted that the TOs were being flagged by the staff but not authenticated by the providers.

Based on MR review1 of 2 staff interviews (staff A), and P/P review this facility failed to 1. Individualize care plans in 3 out of 4 out of a total of 6 patients who required care plans (Pts # 1, 2, and 3), and 2. Failed to complete pain assessments per the care plan for 2 out of 2 out of a total of 4 patients who received interventions for pain (Pt. #1 and 3). Failure to develop individualized patient plans of care and perform pain assessments/reassessments has the potential to affect all patients receiving care in this facility, including the 6 patients present during the survey.

Findings include:

The facility's policy titled, "Plan of Care," dated September 5, 2013, was reviewed on 10/21/2013 at 2:30 p.m. The policy states in part that the plan of care will include, but not be limited to: 2. Realistic, individualized patient care outcomes with established time frames."

The facility's policy titled, "Pain Management (Adult)," dated September 5, 2013 was reviewed on 10/21/2013 at 2:30 p.m. The policy states in part on page 2, "3. Patient's pain level is assessed at the time of admission, at least once during every 8 hours shift, and more frequently as clinically indicated...5. Reassess and document for effectiveness of each intervention of prn [as needed] medication administration or after a change in scheduled pain medication: Within 30 minutes following IV/IM [intravenous/intramuscular]; Within on hour following an oral medication."

In regards to documentation the policy states, "1. Documentation includes initial assessment findings and any reassessment findings including intensity, location, quality/characteristic and pain scale assessment. 2. Pain management is documented according to established procedures."


A MR review was conducted on 10/21/2013 at 10:40 a.m. on Pt. #1's closed OB record accompanied by HIM Mgr B. Pt. #1 was admitted to the facility on 10/19/2013 for childbirth and was discharged on 10/20/2013.
Care Plan: Pt. #1's care plan is a standardized computer generated care plan that has not been individualized to Pt. #1's specific needs.
Pain: Pt. #1 was given ibuprofen for pain on 10/20/2013 at 4:30 a.m. and 9:46 a.m. There is no documented assessment or reassessment for pain in Pt. #1's MR for either time period Pt. #1 received medication.
HIM Mgr B agreed that there was no pain assessment or reassessment documented at the time of the MR review.

A MR review was conducted on 10/21/2013 at 11:33 a.m. on Pt. #2's closed newborn record accompanied by HIM Mgr B. Pt. #2 was born on 10/19/2013 and was discharged on 10/20/2013.
Care Plan: Pt. #2's care plan is a standardized computer generated care plan that has not been individualized to Pt. #2's specific needs. There is no individualization to the outcomes or the goals from the generic care plan. Pt. #2 also had a circumcision on 10/20/2013 and there is no care plan for this.
HIM Mgr B agreed with the findings at the time of the MR review.

A MR review was conducted on 10/21/2013 at 11:46 a.m. on Pt. #3's closed MR accompanied by HIM Mgr B. Pt. #3 was admitted to the facility on 10/14/2013 for confusion and an intestinal inflammation and was discharged on 10/18/2013.
Care Plan: Pt. #3's care plan is a standardized computer generated care plan that has not been individualized to Pt. #3's specific needs. Pt. #3 had medication ordered for pain, which Pt. #3 did receive, however there is no pain care plan initiated.
Pain: Pt. #3 had Dilaudid IV and Vicodin orally ordered for pain management. On 10/15/2013 Pt. #3 received Dilaudid at 7:40 a.m. At 8:00 a.m. there is a documented pain rate of 10 (20 minutes after the pain medication is given), and no pain reassessment. At 2:20 p.m. Pt. #3 received another dose of Dilaudid and there is no documented assessment or reassessment of pain.
HIM Mgr B agreed with these findings at the time of the MR review.

In an interview with CNO A on 10/21/2013 at 11:50 a.m. regarding pain assessments and documentation, A stated that it is the expectation that pain assessments are documented at the time they are performed and reassessments are performed and documented within the parameters of the policy. In the case of Pt. #3, with the use of IV medication for pain, the expectation would have been to document a reassessment within 30 minutes and there are several different places within the electronic record one could look to determine if this was done.



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