HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the Governing Body failed to ensure the Medical Staff was accountable and failed to enforce the Rules and Regulations as they applied to the dating and timing of verbal orders in nine (9) of nine (9) medical records (1, 2, 3, 4, 5, 7, 8, 9 and 10) reviewed. This has the potential to leave patient's medical records incomplete and leave the records without a time line to follow related to carrying out of the orders.
Findings include:1. Bylaws, Rules and Regulations of the medical staff state in part: "verbal orders are acceptable only under urgent circumstances when it is impractical for such orders to be given in written form by the responsible physician, and should be authenticated within 48 hours."

2. Patient #1 presented to the Emergency Department (ED) on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

3. Patient #2 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

4. Patient #3 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

5. Patient #4 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

6. Patient #5 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

7. Patient #7 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

8. Patient #8 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

9. Patient #9 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

10. Patient #10 presented to the ED on 6/23/11. Verbal orders (preprinted) were not dated or timed, and when the physician signed off the orders, he failed to date and time the orders.

11. These medical records were reviewed with the Clinical Director of the ED in the afternoon of 8/2/11 and the morning of 8/3/11 and she agreed with these findings.

Based on review of medical records and staff interview it was determined the hospital failed to ensure discharge vital signs were being completed on patient's prior to discharge from the Emergency Department (ED) in six (6) of nine (9) medical records reviewed (#1, 2, 3, 4, 5 and 7). This has the potential to negatively affect patient care as staff would not be aware of a change in the patient's status.

Findings include:

1. During an interview with the Clinical Director of the ED in the afternoon of 8/2/11 she stated the expectation of the staff is to ensure discharge vital signs are completed on every patient prior to them leaving the unit.

2. Patient #1 presented to the ED on at 2207 on 6/23/11. He was discharged at 0442 on 6/24/11. There was no documented evidence of discharge vital signs.

3. Patient #2 presented to the ED at 2213 on 6/23/11. She was discharged at 0207 on 6/24/11. There was no documented evidence of discharge vitals signs.

4. Patient #3 presented to the ED at 2218 on 6/23/11. She was discharged at 1257 on 6/24/11. There was no documented evidence of discharge vitals signs.

5. Patient #4 presented to the ED at 2224 on 6/23/11. He was discharged at 2320 on 6/23/11. There was no documented evidence of discharge vitals signs.

6. Patient #5 presented to the ED at 2234 on 6/23/11. He was discharged at 0100 on 6/24/11. There was no documented evidence of discharge vitals signs.

7. Patient #7 presented to the ED at 2320 on 6/23/11. She was discharged at 0223 on 6/24/11. There was no documented evidence of discharge vitals signs.

8. These medical records were reviewed with the Clinical Director of the ED in the afternoon of 8/2/11 and again in the morning of 8/3/11 and she agreed with these findings.