HospitalInspections.org

Based on medical record review, policy review, and staff interview it was determined the facility failed to ensure that medical records were complete, accurate, and/or authenticated with date and time, for 3 of 4 (#1, #2 and #4) patients whose records were reviewed. This had the potential to result in insufficient information to identify the patient, document the course of care, and promote continuity of care. Findings include:

The hospital's Medical Staff By-laws stated "All orders shall be in writing. If the physician is absent from the Hospital, an order shall be considered to be in writing if desired over the telephone by the physician to a licensed nurse. Orders dictated over the phone shall be signed by the person to whom dictated, including the name of the physician, date, and time." The By-laws also included "Physician's orders are required for admission..." These By-laws were not followed. Examples include:

1. Patient #1 was a 23 year old male admitted to the facility on 11/23/14, for self harm.

Patient #1's record was reviewed and contained a form titled Admission Physician Orders and Medication Reconciliation. The form was dated 11/23/14 with an admission time of 5:10 PM and signed by an RN at 3:00 PM, on the same date. The form contained a section titled Standing Orders Medications. Under this section several medications were listed with doses, route to be taken, frequency they may be given, indication for the medication, and an area to circle yes or no, if ordered by the physician. There were also orders under the same section, to substitute an injection of medication for a pill if necessary, catheterize a patient to obtain urine as necessary, and crush medications. All of the standing orders had "yes" circled.

Near the bottom of the same form was a section, with instructions to check a box next to the name of the physician listed, who would be admitting the patient. Next to each name was a signature line and an area for the date and time. This area was blank with no physician name marked, and there was no signature or date and time.

At the bottom of the form, in large capital letters, was a statement which read "CHECK HERE WHEN TELEPHONE ORDERS ARE READ BACK"." The box was not marked.

The admission and order form had no documentation that a physician was called or the patient was admitted under the care of a physician.

During an interview on 11/24/14 at 9:55 AM, the CAO reviewed the record. She confirmed the admission order form was not signed by the physician and the box was not checked to indicate these were telephone orders. The CAO confirmed there was no documentation in Patient #1's record that the physician had been called.

During an interview on 11/24/14 at 3:15 PM, the RN confirmed he filled out the admission and medication reconciliation form. He confirmed there were no marks next to a physician's name, as an admitting physician, and there was not a check in the box that these were telephone orders. The RN stated he did speak with the physician to obtain the orders and admit Patient #1 but did not document it in the record.

Patient #1's record was not complete and did not have documentation the physician was contacted by the RN for admission and medication orders.

2. Patient #2 was a 27 year old male admitted to the facility on 11/24/14 at 2:40 AM.

Patient #2's record included telephone admission orders, dated 11/24/14 at 1:30 AM, documented by an RN. The admission standing orders included numerous items, such as:

-Tylenol 650 mg, PO, Q 4 hrs PRN, for mild pain
-Trazodone 50 mg, PO, HS, PRN for insomnia
- May substitute Zydis as necessary for all Zyprexa orders
- May straight catheter as necessary if unable to obtain a clean catch UA by day three of admission

The admission order form included "CHECK HERE WHEN TELEPHONE ORDERS ARE READ BACK", in large font at the bottom. The box was not checked. The admission order form did not include verification the RN spoke with the physician at the time of admission.

During an interview on 11/24/14 at 3:30 PM, the admitting physician for Patient #2 reviewed Patient #2's record. He confirmed that the RN called him for admitting orders, although the contact was not document.

The CAO was interviewed on on 11/24/14 at 3:40 PM. She confirmed the RN should have checked the box when documenting the admission telephone orders.

Patient #2's telephone admission orders did not include verification of contact with the admitting physician.

3. Patient #4 was a 50 year old admitted to the facility on 11/23/14 at 12:30 PM.

Patient #4's record included admission telephone orders dated 11/23/14 at 12:35 PM, five minutes after admission. The admission standing orders included numerous items, such as:

-Tylenol 650 mg, PO, Q 4 hrs PRN, for mild pain
- May substitute Zydis as necessary for all Zyprexa orders
- May straight catheter as necessary if unable to obtain a clean catch UA by day three of admission

The admission order form included "CHECK HERE WHEN TELEPHONE ORDERS ARE READ BACK", in large font at the bottom. The box was not checked. The admission order form did not include verification the RN spoke with the physician at the time of admission.

The RN who documented telephone orders was interviewed on 11/24/14 at 3:25 PM. He confirmed he should have checked the box when documenting the admission telephone orders.

Patient #2's telephone admission orders did not include verification of contact with the admitting physician.




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