HospitalInspections.org

Based on observation, interview, record review and policy review the facility failed to ensure the staff authenticate verbal orders with the physician name, date and time of authentication for six (#1, #2, #5, #7, #8, #9) of nine current patients. The facility census was nine.

Findings included:

Record review of the facility policy titled, "Verbal Orders by the Physician" dated 05/27/08 showed the following:
Procedure: Verbal Orders:
The prescriber shall co-sign the order within 24 hours or the next time he/she provides care to the patient, assesses the patient, or documents information in the patient's medical record if sooner then (sic) 24 hours.

Record review of current patient #1's medical record showed the patient had been admitted to the facility on 04/11/11 for antibiotic therapy.

Record review of the verbal Orders for Treatment did not have the date or time of the physician' signature:
- 04/11/11 at 12:30 PM
-04/13/11 at 10:15 PM
-04/13/11 at 10:25 PM
-04/14/11 at 7:50 AM
-04/14/11 at 10:00 AM
-04/14/11 at 11:00 AM
-04/15/11 at 2:40 PM
-04/15/11 at 3:45 PM
-05/11/11 at 1:30 PM

Record review of the Telephone Orders for Treatment showed no date or time of the physician's signature
--04/12/11 at 11:00 AM
-04/12/11 at 2:15 PM
-04/14/11 at 10:25 AM
-05/09/11 at 7:20 AM

Record review of the HADH (Hermann Area District Hospital) Code Status Orders showed the physician had signed the order but had not dated or timed the order.

Record review of current patient #2's medical chart showed the patient had been admitted to the facility on 05/04/11 for wound management.

Record review of the verbal Orders for Treatment did not have a date or time of the physician's signature:
-04/20/11 (no time)
-04/21/11 at 9:56 AM
-05/06/11 at 9:50 AM
-05/08/11 at 4:30 PM
-05/10/11 at 3:00 PM

*Record review of the telephone Orders for Treatment dated 04/26/11 at 11:30 AM showed no authentication with physician's signature, date and time.

Record review of the telephone Orders for Treatment showed no date or time of the physician's signature:
-04/26/11 at (no time)
-04/26/11 at 10:30 AM
-05/04/11 at 9:00 AM
-05/08/11 at 1:00 PM

Record review of #5's medical record showed the patient had been admitted to the facility on 04/21/11 for intractable back pain.

Record review of the verbal Orders for Treatment showed no date or time of the physician's signature:
-04/21/11 at 12:25 PM
-05/10 at 1:50 PM


Record review of the telephone Orders for Treatment showed no date or time of the physician's signature:
-04/21/11 at (no time)
-05/11/11 at 10:10 AM

Record review of #7's medical record showed the patient had been admitted to the facility on 04/29/11 for reconditioning.

Record review of the verbal Orders for Treatment showed no date or time of the physician's signature.
-05/08/11 at 9:15 AM
-05/08/11 at 9:30 AM
-05/08/11 at 1:15 PM


Record review of the telephone Orders for Treatment showed no date or time of the physician's signature:
04/29/11 at 4:45 PM


Record review of the HADH (Hermann Area District Hospital) Code Status Orders showed the physician had signed the order but had not dated or timed the order.

Record review of #8's medical record showed the patient had been admitted to the facility on 05/06/11 for fracture of the left arm.

Record review of the telephone Orders for Treatment showed no date or time of the physician's signature:
-05/06/11 at 2:40 PM
-05/11/11 5:30 PM

Record review of the HADH (Hermann Area District Hospital) Code Status Orders showed the physician had not signed, dated or timed the order.

Record review of #9's medical record showed the patient had been admitted to the facility for 23 hour observation on 05/11/11 for high blood sugar, chest pain and suicidal ideation.

Record review of the telephone Orders for Treatment showed no date or time of the physician's signature:
-05/12/11 at 5:25 AM
-05/12/11 at 9:25 AM

An interview on 05/12/11 at 9:50 AM Staff B, RN (Registered Nurse), stated that the verbal orders were signed by the physician but not dated or timed. And the HADA directing staff what to do in case a patient would have a cardiac or respiratory arrest is not complete either because the physician did not sign or did not date and time.