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Based on record reviews, staff interviews, and review of the medical staff by-laws, the hospital failed to ensure that medical staff providers followed the governing body approved Medical Staff Rules and Regulations pertaining to the authentication of verbal orders within 48 hours for 6 (#s 1, 2, 3, 4, 6, and 7) of 8 records reviewed. Findings include:

On 2/20/13 at 11:00 a.m., the review of 6 medical records revealed that verbal orders for restraint and seclusion, medications, and laboratory tests were not signed or authenticated within the required 48 hours time period. (see tag A457)

A review of the current approved medical staff by laws was completed on 2/20/13 at 1:00 p.m. The bylaws, under the section labeled 'Purpose' included the following statements.
Purpose- "...adopt bylaws, rules and regulations which establish a framework for the self-governance of Medical Staff activities and a framework for accountability within the organization;"
-Medical Staff Obligation- "Acceptance of membership to the Medical Staff shall constitute the staff member's agreement to maintain professional growth and develop standards as established in the Rules and Regulations;" and
-Medical Records- "All orders for medication or medical treatment must be either written by the ordering practitioner or accepted and transcribed into written form by the licensed or registered nurse whom dictated, as per the name of the practitioner. The ordering physician, or the attending physician, or his/her physician designee must counter sign, date, and time urgent verbal orders with in 48 hours. All orders shall be signed date, and timed by the ordering practitioner or, in the care of verbal orders, by the authorized person caring for the patient."

On 2/21/13 at 9:30 a.m., the DON stated that all initial orders for seclusion and restraints should be signed with in 24 hours while the physician is completing the initial face-to-face. All other verbal orders were to be authenticated within 48 hours of receiving the order.

On 2/21/13 at 10:30 a.m., a physician stated that there was "no reason why the verbal orders can not be signed with in the 48 hours time frame." The physician stated that there is always a physician at the hospital including weekends. The physicians have been trained to review the chart and look for orders to be signed. The physician further stated that there was no reason why the initial order for a restraint and seclusion could not be signed within 24 hours.

Based on policy reviews and staff interview, the hospital's Seclusion and Restraint policy failed to define authentication of verbal orders? for medical treatment and medications. Findings include:

A review of the medical staff by laws was completed on 2/20/13 at 1:00 p.m. The bylaws, under the section labeled 'Purpose' included the following statement.
-Medical Records "All orders for medication or medical treatment must be either written by the ordering practitioner or accepted and transcribed into written form by the licensed or registered nurse whom dictated, as per the name of the practitioner. The ordering physician, or the attending physician, or his/her physician designee must counter sign, date, and time urgent verbal orders with in 48 hours. All orders shall be signed date, and timed by the ordering practitioner or, in the care of verbal orders, by the authorized person caring for the patient."

A review of the facility Seclusion and Restraint policy was completed on 2/20/13 at 2:00 p.m. The policy did not define a time frame for the authentication of verbal orders for restraint and/or seclusion use. when verbal orders needed to be authenticated. The Seclusion and Restraint policy, under the section labeled Responsibilities, included the following statements:
-"promptly notify the physician, LIP, or RN when a patient was in imminent danger to self or others; and
- Verbal orders will be obtained from a physician or LIP, prior to or after the emergency use of restraint and seclusion."
The policy did not define the required time frame of no longer than 48 hours within which verbal orders were to be authenticated per the Medical Staff By Laws.

On 2/21/13 at 10:30 a.m., the unit manager stated that promptly notifying the provider meant the verbal orders would be signed within 24 hours. The verbal orders for seclusion and restraints should be signed by a provider during the first initial face-to-face contact.

?Huffman, E.K., Finnegan, R, & Amatayakul (1990). Medical record management (9TH ed.). Berwyn, Illinois: Physician ' s Record Company.

According to Huffman et al, " Medication orders may be recorded by a licensed nurse, a registered pharmacist, or physicians assistant. These must be signed within 48 hours by the prescribing/attending physician. "

Based on record reviews, staff interviews and policy review, the hospital failed to ensure that verbal restraint and seclusion orders were properly authenticated by the ordering physician within 48 hours? for 6 (#s 1, 2, 3, 4, 6, and 7) of 8 records reviewed. Findings include:

The review of clinical records, beginning on 2/20/13 at 11:00 a.m., revealed the following documentation issues:
1. Patient #1 was admitted to the facility on 1/20/13. The initial verbal order for restraint and/or seclusion was entered into the record on 1/24/13 by the nurse on duty. The order was initiated on 1/24/13. The verbal order was not authenticated by signature of the ordering physician until 1/29/13.
The record contained additional orders:
-the verbal order for seclusion on 1/24/13;
-the verbal order for seclusion on 1/25/13;
-the verbal order for seclusion on 1/25/13;
-the verbal order for seclusion on 1/25/13 had no date or time; and
-the verbal order for seclusion on 1/25/13.
All of the above verbal orders were signed by the physician on 1/29/13 at 12:00 p.m. This was beyond the 48 hour requirement.

2. Patient #2 was admitted to the facility on 2/15/13. The initial verbal order for restraint and/or seclusion was entered into the record on 2/16/13 by the nurse on duty. The order was initiated on 2/16/13. The following verbal orders were not signed with in the 48 hours requirement:
-the verbal order for seclusion on 2/17/13 ;
-the verbal order for seclusion on 2/17/13; and
-the verbal order for seclusion on 2/17/13;
There was a verbal order dated 2/17/13 at 1755 for Ativan 1 mg Po now for increased tension. The verbal order was not signed by a physician until 2/20/13. This was beyond the 48 hours requirement.

3. Patient #3 was admitted to the facility on 7/24/12. The initial verbal order for restraint and/or seclusion was entered into the record on 1/20/13 by the nurse on duty. The order was initiated on 1/27/13. The verbal order was received on 1/27/13 and was not signed by a physician until 2/13/13. This was beyond the 48 hours requirement.

4. Patient #4 was admitted to the facility on 1/29/13. The initial verbal order for restraint and/or seclusion was entered into the record on 1/29/13 by the nurse on duty. The order was initiated on 1/29/13.
The following verbal orders were not signed with in the 48 hours requirement:
-a verbal order for seclusion on 1/29/13;
-a verbal order for seclusion on 1/29/13;
-a verbal order for seclusion on 2/1/13 ; and
-a verbal order for seclusion on 2/2/13.
The verbal orders were not signed by a physician until 2/13/13. This was beyond the 48 hours requirement.

5. Patient #6 was admitted to the facility on 9/9/12. The following verbal orders were not signed in a timely manner:
-on 9/27/12, a clarification verbal order for Cogentin one tablet every six hours as needed was entered into the record. The verbal order was not authenticated by a physician until 10/4/12;
-on 9/18/12 an order for a laboratory draw for a vitamin D level was entered into the record. The verbal order was not authenticated by a physician until 9/24/12; and
-on 9/12/12 an order for a CMP lipid panel was entered into the record. The order was not authenticated by a physician until 9/17/12 .

6. Patient #7 was admitted to the facility on 10/9/12. The following verbal orders were not signed in a timely manner:
-on 10/26/12 an order for Zyprexa 10 mg Po now, one time, was entered into the record. The verbal order was not authenticated by a physician until 10/30/12;
-on 10/26/12 an order for Benadryl 50 mg by mouth, every 6 hours as needed, was entered into the record. The verbal order was not authenticated by a physician until 10/30/12;
-on 10/25/12 an order for Zyprexa 10 mg Po now, one time, was entered into the record. The verbal order was not authenticated by a physician until 10/30/12;
-on 10/24/12 an order for Ativan 2 mg IM one time, now, was entered into the record. The verbal order was not authenticated by a physician until 10/30/12;
-on 12/3/12 a verbal order for seclusion was entered into the record. The verbal order was initiated and not signed until 12/6/12;
-on 12/3/12 a verbal order for seclusion entered into the record. The verbal order was initiated and not signed until 12/6/12;
-on 12/4/12 a verbal order for seclusion was entered into the record. The verbal order was initiated and not signed or timed by the physician; and
-on 12/4/12 a verbal order for seclusion was entered into the record. The verbal order was initiated and not signed by a physician until 12/7/12.

A review of the medical staff by laws was completed on 2/20/13 at 1:00 p.m. The by laws documented that "All orders for medication or medical treatment must be either written by the ordering practitioner or accepted and transcribed into written form the licensed or registered nurse whom dictated, as per the name of the practitioner. The ordering physician, or the attending physician, or his/her physician designee must counter sign,date, and time urgent verbal orders with in 48 hours. All orders shall be signed date, and timed by the ordering practitioner or, in the care of verbal orders, by the authorized person caring for the patient."

On 2/21/13 at 9:30 a.m., the DON stated that all initial orders for seclusion and restraints should be signed with in 24 hours while the physician is completing the initial face-to-face. All other verbal orders are to be authenticated with in 48 hours of receiving the order.

On 2/21/13 at 10:30 a.m., a physician stated that there was "no reason why the verbal orders can not be signed with in the 48 hours time frame." The physician stated that there is always a physician at the hospital even on the weekends. The physicians have been trained to review the chart and look for orders to be signed. The physician further stated that there was no reason why the initial order for a restraint and seclusion could not be signed within 24 hours.

?Huffman, E.K., Finnegan, R, & Amatayakul (1990). Medical record management (9TH ed.). Berwyn, Illinois: Physician ' s Record Company.

According to Huffman et al, " Medication orders may be recorded by a licensed nurse, a registered pharmacist, or physicians assistant. These must be signed within 48 hours by the prescribing/attending physician. "