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Based on review of policy and procedures, record review and staff interview, the CAH (Critical Access Hospital) failed to ensure nursing staff followed the procedure for documenting the receipt of telephone/verbal orders in the Emergency Room (ER) for 2 of 5 patients (Patients 21 and 22). This had the potential to effect any patients treated in the ER The CAH provided ER services to 1,039 patients for the last fiscal year of 7/1/14 through 6/30/15.

Findings are:

A. A review of Patient 21's ER Order form dated 1/4/15 indicated the following orders:
DIAGNOSTICS
- Lab: CBC (complete blood count-a lab test to measure the red blood cells in blood), CMP (comprehensive metabolic profile-a lab test to measure the body's chemical balance in the blood) and UA (urinalysis)
- Radiology: Chest XR (x-ray)
INTERVENTIONS
- Initiate IV (intravenous-giving fluid through the vein) of NS (normal saline-a sterile mixture of salt water) at 500 cc/hr (cubic centimeters per hour) x (by) 1 hr then decrease to 100 cc/hr
- Oxygen at 4 l/min (liters per minute) per NC (nasal cannula)
DISCHARGE FROM ER
- Admit to Inpatient Acute Care at 1846 (6:46 PM)

This grouping of ER orders was noted by 2 nurses on 1/4/15 at 1815. The ER Order form did not identify what physician or provider gave the orders, how the orders were received (via telephone or verbally) and what nurse received the order from the physician or provider.

B. A review of Patient 22's Emergency Room Order form dated 3/11/15 indicated the following orders:
INTERVENTIONS
- Tdap (tetnus shot) vaccine IM (intramuscular- shot in the muscle) x 1; Dermabond (glue that forms a bond between wound edges); Cleanse wound-betadine (disinfectant) scrub; irrigate wound
- Laceration (cut) repair
DISCHARGE FROM ER
- Monitor for s/s (signs and symptoms) of infection; limit activity activity tonight
- Discharge from the ER to return to home, condition on discharge stable.

This grouping of ER orders was noted by 2 nurses on 3/11/15 at 1842 (6:42 PM). The ER Order form did not identify what physician or provider gave the orders, how the orders were received (via telephone or verbally) and what nurse received the order from the physician or provider.

C. Review of Policy #502 last reviewed and revised 6/14 identified the procedure:
If written, verbal and telephone orders are written with the time they are received. They are written as follows:
"RTO/RVO (Read Back Telephone Order/Read Back Verbal Order) Dr (doctor). X, Nurse, RN (Registered Nurse)"
"RTO/RVO J.Jones PA (Physician Assistant)/Dr. X, Nurse, RN
Note: PA/APRN (Advanced Practice Registered Nurse) orders must also include the MD (doctor) backup name."

D. Interview with the Director of Nurses on 7/13/15 at 3:30 PM revealed, "Yes, neither of those orders (for Patients 21 & 22) have it identified who gave the order or who took the order. I had identified that there were problems with telephone and verbal orders, but now since the middle of March we have moved to CPOE (Computerized Physician Order Entry) and hopefully that will take care of it."