HospitalInspections.org

Based on clinical record review and interview, it was determined the facility failed to follow established policies and procedures regarding Physician's orders for 3 (Patient #1, #5 and #6) of 10 (Patient #1-10) clinical records reviewed. The failed practice created the potential for procedures and other treatments to be conducted without authorization of a physician and had the potential to affect all patients admitted to the Emergency Department. The findings follow:

A. Review of Hospital policy 12.1.1 on 02/01/12 revealed, "Medical care may be given to patients in the Hospital only by or on the order of a Practitioner who has been granted appropriate Clinical Privileges".
B. Review of Patient #1's clinical record revealed the patient received an In & Out Catheter. Review of the physician's orders revealed there was no evidence an order was written or given for an In & Out Catheter.
C. Review of Patient #5 and #6's clinical records revealed the patients received Foley catheters. Review of the physician's orders revealed there was no evidence an order was written or given for Foley catheters.
D. The above was confirmed by the Emergency Room Director at 1340 on 01/30/12.