HospitalInspections.org

Based on review of medical records and staff interviews the facility failed to ensure 3 out of 10 patient charts (#4, #5, #6) had all orders, including verbal admission physician orders signed, dated, timed, and authenticated promptly by the ordering practitioner.

Findings were:

In review of facility policy titled Verbal Orders, Policy Number HIM-01.11, Revised Date: 2/1/2017, 4/1/2019 stated in part,

"...PURPOSE:
To ensure that only qualified staff give, receive, read back and record verbal orders.

POLICY:
Qualified staff receives and record verbal orders.

PROCEDURE:

1. Verbal orders will be given only by qualified physicians, non-physician practitioners or other persons licensed or authorized to prescribe by the State in which the order is being given.

2. The following staff members are authorized to receive, read back and record verbal orders:

o Registered Nurses (RN)
o Licensed Vocational or Practical Nurses (LVN/LPN),
o Other Allied Health Professionals (AHP) within the scope of their professional practice.

3. Documentation of verbal orders must include all components of a valid written order. It must also contain the date, time and the name of individual who issued the order as well as the name and title of the person who, received and recorded the order.

4. Verbal orders should be authenticated by the prescriber within the timeframes specific to the state in which the order is executed.

Texas =within 96 hours of date order is given; with the exception of the admit order which if given verbally must be authenticated within 24 hours.

Louisiana = within 10 days of date order is given.

Mississippi = the next regular working day, but in all events within 72 hours..."

In reviewing patient records #4, #5, and #6 the verbal admission physician orders did not have a physician signature, date or time on the order in the allotted 24 hours for Texas.

In an interview with facility COO and CNO on the afternoon of 03/22/2022, the above findings were confirmed.