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Based on the review of the medical records, policy and procedures, interviews, employee records and quality data, it was determined that the facility failed to ensure verbal order for discharge was documented in the medical record.

Findings were:

Review of medical records #1, #2 and #3 revealed that one (1) of three (3)medical records #1 lacked evidence the patient received a written order for discharge to hospice.

Review of the facility policy, entitled "Provider Orders" , revised 04/17/12, revealed that verbal orders must be signed with the writer, printing the name of the person submitting order and signing his/her name and title followed by (RVB - indicating the order has been read back and approved. An approved licensed personnel includes Registered Nurses (RN) and Licensed Practical Nurses (LPN). The orders must be signed a by a Licensed Independent Practitioner (LIP).

Review of the physicians' order sheet had not revealed the patient was written a discharge to go home with home hospice.

An interview was conducted on 03/05/13 at 12:15 a.m. with the physician (credential #1) who stated he/she cared for the patient and had talked with the nurse (employee # 4) and relayed information for the patient's discharge. The nurse stated he/she had wrote the patient would be discharge depending on the patient's test result. The physician explained he/she had a conversation with the nurse, and explained that if the patient's CT test was negative and then the patient could go home. The physician stated the nurse had not notified the physician for a verbal order after the test came back negative. The physician saw the test the next day and still had not given or signed a verbal order.

An interview was conducted with the charge nurse (employee #4) who called back the patient's negative test results to the physician and texted the physician. The charge nurse had spoken with the nurse caring for the patient and told the charge nurse to discharge the patient. The nurse explained the patient went home because his/her CT scan was negative. The charge nurse stated he/she had spoken with the physician and the physician approved for the patient to go home, but he/she had forgotten to write the verbal order for discharge for the patient.

An interview was conducted on 03/05/13 at 12:15 p.m. in the conference room with the Clinical Manager of the medical surgical floor who was involved with the nurse who cared for the patient. The manager stated the physician had written an order for a CT (Computerized Axial Tomography) scan and wanted the patient to go home after the patient had the CT. The manager verbalized the charge nurse (employee #4) had spoken with the physician and relayed the patient's test result and that the physician approved the patient to be discharged but had not wrote a verbal order for discharge. The charge nurse should have written a verbal order for the patient.