HospitalInspections.org

Based on record review and interview the facility failed to ensure that orders for drugs and biologicals are signed by a practitioner for 4 (Patients #1, #2, #3, and #4) of 5 patient records reviewed.

The findings include:

Review of the facility's Nursing Policy and Procedure Manual Section IIIG Charting and Documentation revealed a policy on physician telephone orders. The policy reads: "Telephone orders may be taken, but must be co-signed by the physician within 48 hours with time date and signature."

1. On 2/24/2010 review of clinical records revealed Patient #1 was admitted 2/19/2011. Physician's orders included Labor & Delivery Protocol by telephone order on 2/19/2011, Cervidil Orders by telephone order on 2/19/2011, and Oxytocin administration by telephone order on 2/19/2011. None of these orders were signed by the practitioner.

In an interview on 2/24/2011 at about 4:30 p.m., the Mother/Baby Unit Clinical Manager confirmed that the orders were not signed.

2. On 2/24/2010 review of clinical records revealed Patient #2 was admitted 11/8/2010. Physician's orders included admission orders for testing and routine postpartum orders for medications by telephone order on 11/8/2010, blood and urine testing by telephone order on 11/8/2010, Uncomplicated Vaginal Delivery Protocol by telephone order on 11/8/2010, and Standing Orders for Magnesium Sulfate by telephone order on 11/8/2010. None of these orders were signed by the practitioner.

In an interview on 2/24/2011 at 3:54 p.m., the Director of Patient Advocacy and Regulatory Compliance said that he was unable to determine that the orders had been validated.

3. On 2/24/2010 review of clinical records revealed Patient #3 was admitted 11/25/2010. Physician's orders included admission orders for lab tests by telephone order on 11/25/2010, orders for magnesium sulfate administration, Percocet administration, and uric acid testing by telephone order on 11/25/2010, and Standing Orders for Magnesium Sulfate by telephone order on 11/25/2010. None of these orders were signed by the practitioner.

In an interview on 2/24/2011 at 3:14 p.m., Mother/Baby Unit Clinical Manager confirmed that the orders were not signed.

4. On 2/24/2010 review of clinical records revealed Patient #4 was admitted 12/3/2010. Physician's orders included Standing Orders for Magnesium Sulfate by telephone order on 12/3/2010 and Profile I tests by telephone order on 12/4/2010. None of these orders were signed by the practitioner.

In an interview on 2/24/2011 at 3:51 p.m., the Corporate Counsel confirmed that the orders were not signed.