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Based on staff interview, patient electronic medical record review and review of the facility's policy and procedure, the facility failed to ensure that verbal and/or telephone orders were authenticated by the ordering provider as soon as possible for 4 of 21 medical records reviewed. (Patient record #21, #14, #12 and #11)

The findings include:

A total of 21 electronic patient medical records were reviewed with the assistance of facility staff navigating the electronic record.

A closed medical record review conducted for patient #21 revealed telephone orders that failed to be authenticated by the ordering provider: 05/08/2023 for Ciprofloxacin; 05/08/2023 for Symbicort; 05/09/2023 for Tramadol and lab work; 05/11/2023 for 2 units packed red blood cells; 05/12/2023 for abdomen x-ray; 05/12/2023 for Levophed drip, Midazolam drip and Dopamine.

A closed medical record review conducted for patient #14, admitted on 07/13/2023 revealed telephone orders that failed to be authenticated by the ordering provider. Telephone orders were as follows: 07/16/2023 for Lorazepam; and 07/21/2023 for Loperamide.

A closed medical record review conducted for patient #12, admitted on 09/21/2023 revealed verbal orders that failed to be authenticated by the ordering provider. Verbal orders were as follows: 09/24/2023 for Hydrocodone, Zolpidem, NF-Enbrel, Metformin, Amoxicillin and Eliquis.

A closed medical record review conducted for patient #11, admitted on 09/24/2023 revealed verbal orders that failed to be authenticated by the ordering provider. Verbal orders were as follows: 09/24/2023 for Hydrocodone and Tamsulosin.

On 10/12/2023 at approximately 12:00 PM, an interview was conducted with the Director of Nursing (DON) about the process of ensuring verbal and telephone orders are authenticated. The DON called a Certified Physician Assistant to ask how he signs his telephone orders. He stated, "I have never signed one. I don't even know how I would." The DON confirmed that there were 3 different providers identified, on the above records, that failed to have their orders authenticated by the ordering provider. She immediately reached out to their medical records to ensure this gets addressed with the providers.

A review of the facility's policy and procedure entitled "Verbal / Telephone Orders," No. 001.181 last reviewed 04/2021, indicates "It is the policy of Doctors' Memorial Hospital for verbal communication of prescription or medication orders and test results is limited to urgent situations in which immediate written or electronic communication is not feasible." On page 2, "l. Prescribers will verify, sign, and date orders prior to patient's discharge."

Based on staff interviews and facility policy review, the facility failed to ensure that a properly executed informed consent was obtained for patients receiving anesthesia services prior to surgery being performed.

The findings include:

On 10/10/23 at approximately 1:00 PM, a tour was conducted of the out-patient surgical area. There were no surgical procedures scheduled for this date.

On 10/10/23 at approximately 1:10 PM, an interview was conducted with Nurse A, a Registered Nurse (RN) in the Outpatient Surgical Unit, regarding the facility's process for obtaining informed consent. Nurse A stated that the nurses go over the anesthesia consent with the patients and have them sign the consent, and then the Anesthesiologist will come in and go over with the patient the procedure for anesthesia and ask if they have any questions and then will sign off on the consent. When asked Nurse A if that is a properly executed informed consent, Nurse A confirmed that it was not, that the Doctor should explain first and then have the patient sign and the nurse sign as a witness of the signature.

On 10/10/23 at approximately 1:56 PM, an interview was conducted with the Surgical Nurse Manager RN regarding the informed consent process. The Surgical Nurse Manager stated that the anesthesiologist or surgeon should come in and go over the procedure with the patient, answer any questions and then have the patient sign their consent. The doctor should then sign, followed by the nurse as a witness. The Surgical Nurse Manager confirmed that the nurses have been having the patient sign the anesthesia consents prior to the anesthesiologist coming in to evaluate the patient and go over the process/procedure with them, and that the facility would be educating the nurses to correct this process.

A review of the Hospital Policy Preoperative Anesthesia Evaluation was conducted which revealed:
I. Policy: Clinical activities are based upon established standards of anesthesia care planned to meet the needs of each individual patient and to assure the delivery of appropriate, quality anesthesia related care. Consideration is given, but not limited to the following:
A. Preoperative:
The anesthesiologist performs an evaluation and assessment of the patient prior to the start of the surgical procedure. He/she is also responsible for developing an anesthesia related plan that is specifically designed for each unique patient.

The anesthesia related plan is discussed with the patient and or patient's legal guardian to review all risks, benefits and alternatives including the type of medications for induction, maintenance, and post-operative care. Consent is documented in its entirety within the patients' medical record to demonstrate the patient's and or legal guardians made an informed decision about the proposed anesthesia-related plan.

Prior to rendering anesthesia care the anesthesiologist and or Allied Health Provider (CRNA [Certified Registered Nurse Anesthetist] & / or AA [Anesthesia Assistant]) obtains anesthesia consent from the patient and/or patient's legal guardian, verify the identity of the patient, along with the operative site and side.