HospitalInspections.org

Based on interview, clinical record review and facility policy review it was determined the facility failed to ensure two (2) verbal orders were documented in the clinical record as evidenced by no documentation in the "Medication Administration Record" or "Physician's Order Form" as required per facility policy, "Verbal and Telephone Orders," policy number VII-3, effective date, 01/31/11, for one (1) of ten (10) sampled patients, (Patient #1).

The findings include:

Review of facility policy, "Verbal and Telephone Orders," number VII-3, effective date 01/31/11, revealed personnel authorized to receive verbal orders should write down the complete order, then read it back and receive the confirmation from the individual who gave the order. It further revealed staff would indicate they had performed a read back of the complete order and received confirmation that the order was correct by signing the order off using their first initial, last name, professional title, date and time.

Interview with the Advanced Practice Registered Nurse (APRN), by telephone, on 01/04/12 at 8:57 AM, revealed she gave two (2) verbal orders for Haldol (an antipsychotic medication used to treat schizophrenia) 2 milligrams (mg) via intramuscular (IM) injection to Patient #1, on 11-06-11, exact times unknown. She further revealed she received the first order from the Physician because Patient #1 was very agitated and was threatening staff. She stated she went to Patient #1's room; however, she did not recall who took the verbal order, who gave the injection or if she documented this action. The APRN further revealed she came back to Patient #1's room in a few minutes because a "Code White" was called (per facility policy "Code White," procedure number II-20, effective date, 04/09/10, a Code White is used to provide a rapid response of identified personnel to attempt to verbally de-escalate the situation and minimize the risk of harm to patients, family, visitors and staff until it can be contained or resolved). She stated the first Haldol injection was not having the desired effect, so she called the Physician. The Physician gave the APRN an order for another IM injection of Haldol 2 mg. The APRN stated she could not recall how much time elapsed between injections or if she documented the order; but she gave the second verbal order. The APRN could not remember who gave the second injection. She further stated Patient #1 became much calmer after the second injection, and the Physician arrived in Patient #1's room shortly after the second injection.

Interview with the Physician, on 01/03/12 at 4:17 PM, by telephone, revealed he gave both orders for Haldol 2 mg IM to the APRN by telephone, on 11/06/11, exact times unknown, for Patient #1. He further revealed when he arrived in Patient #1's room, after both injections, he/she was calmer. The Physician stated it was his oversight that the medication ordered and given was not documented, but the situation was extremely hectic.

Interview with Registered Nurse (RN) #1, by telephone, on 12/30/11 at 4:15 PM, revealed she was the individual that gave the two (2) Haldol 2 mg IM injections to Patient #1, on 11/06/11, exact times unknown. She stated Patient #1 was not her assigned patient, and she had gone to Patient #1's room to help with his/her care. RN #1 stated she did not document giving the injections, because she thought the injections would have been documented on a "Rapid Response Sheet." She further revealed she received the two (2) verbal orders for the Haldol injections from the APRN.

Review of the clinical record of Patient #1 revealed he/she was admitted to the facility, on 11/03/11, with diagnoses of gastrointestinal bleeding and schizophrenia. "Physician's Order Form, Progress Notes," on 11/06/11 at 4:30 PM, written by the APRN, revealed Patient #1 was combative, angry, accusing staff of trying to poison him/her with his/her lunch tray, refusing blood transfusions and demanding his/her intravenous (IV) line be removed. "Physician's Order Form, Progress Notes," on 11/06/11 at 6:03 PM, written by the Nursing House Supervisor, revealed a "Code White" was called for Patient #1 due to the patient being combative and wanting to leave the facility. The note also revealed Patient #1 thought the staff was trying to poison him/her through meals and drinks. Further review of the clinical record revealed a Physician Order for violent restraint was given and initiated, on 11/06/11 at 6:15 PM. The "Violent Restraint Order Form," documented by the Physician, on 11/06/11 at 7:05 PM, revealed an incorrect documentation that Patient #1 received Haldol 2 mg IV instead of the two (2) Haldol 2 mg IM injections. There was no further documentation concerning the Haldol 2 mg IM injections in the clinical record; not in the "Medication Administration Record" or the "Physician's Order Form."