HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to ensure that verbal orders were accepted by individuals who were permitted by Federal and state laws and hospital policy to accept verbal orders.

Findings included:

1. Review of the hospital's policy titled, "Medical/Professional Staff Orders-Transcription," revised 09/26/16, showed the following:
- Telephone orders may be used when the practitioner was not available on the unit and an order was needed for patient care.
- Nursing staff were to use the recognized "read back" verification process and all telephone and voice orders were read back by the nurse to the practitioner for clarification.
- Orders would be transcribed after receiving either written or verbal orders from the physician by the Registered or Licensed Practical Nurse.
- Staff were to specify that the orders had been transcribed by signature, date and time in the designated space.

Review of the hospital's document titled, "Amended and Restated Rules and regulations of the Medical Staff," revised 09/30/19, stated that orders dictated over the phone shall be dated and timed by the person who took the order and shall include the name of the physician or practitioner giving the order, the person who took the order shall read the order back to the ordering physician for confirmation of the order. In case of an emergency, an order shall be considered to be written if dictated by telephone to a licensed nurse and authenticated by the ordering practitioner or attending physician within 24 hours.

Review of Patient #36's medical record showed that she was a 20 year old female who presented to the hospital on 10/20/21 around 1:40 AM, with suicidal ideation (SI, thoughts of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death) with a plan to hang herself, overdose or slit her wrists. Her plan to harm others included shooting them. A verbal order for admission to the unit and suicide risk precautions given by Staff CC, Psychiatrist, was signed by Staff K, Registered Nurse (RN), on 10/20/21 at 2:27 AM.

During an interview on 10/20/21 at 10:50 AM, Staff K, RN, stated the following:
- Staff JJ, Manager of Assessment and Referral (A&R), Counselor, brought her the telephone order, for Patient
#36, when her shift began at 7:00 AM, and asked her to sign it.
- She signed the already dated and timed telephone order to admit Patient #36 but she didn't receive the order as she was not in the hospital during the time the telephone order was received..
- She did not feel that she should sign a physician's order that she did not receive.

After being asked by this surveyor if she should sign a physician's order that she did not receive did Staff K, RN, consider that she should not have signed an order that she did not receive.

During an interview on 10/20/21 at 1:07 PM, Staff CC, Psychiatrist, stated that Staff JJ, Manager of A&R, Counselor, called him on the telephone regarding Patient #36's admission to the unit and that nurses were the only staff allowed to take telephone orders.

During an interview on 10/20/21 at 4:27 PM, Staff JJ, A&R Manager, Counselor, stated that:
- He sometimes called the physicians to discuss patients and give a report, but it was up to the nursing staff to obtain orders.
- He was not qualified to take a physician's telephone order or a verbal order for anything.
- He attempted to get Staff HH, RN, House Supervisor to sign one of the patient's paperwork but he could not find her so he took it to Staff K, RN after she arrived for her day shift.
- He routinely took any paperwork that needed a nurse signature to any nurse and had them sign.

Non-qualified staff accepted telephone orders from physicians and nursing staff were asked to put their signature on paperwork, even when they were not present at the time indicated by the signature.