HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that the nursing policy for verbal orders which required the naming of the involved medication were implemented for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility on 3/31/16 at 9:14 AM. Physician telephone orders of 3/31/16 at 12:46 PM, were handwritten by a nurse in the medical record and read, "Give 300 MG (milligrams) oral PO X 1 in PACU."

The hospital policy "Medication Ordering/Prescribing" read, "Health First will be compliant with all documentation with regard to completeness, legibility, clarity....The Licensed Healthcare Provider will clarify with the prescriber when questions or concerns arise.... Complete medication orders include medication name...." The order as written was not in compliance with this policy, because the name of the medication was not specified.

During an interview of the Risk Manager at approximately 7:15 PM on 4/29/16, she confirmed the findings.