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Based on record and policy review it was determined the facility failed to ensure that appropriate physician orders are obtained and authenticated for the use of patient restraints for one (#3) of 12 records reviewed. This practice does not ensure safe use of restraints.

Findings include:

Patient #3's physician orders, reviewed on 4/5/12 at approximately 11:10 a.m., revealed a telephone order for soft wrist restraints to be applied on 3/30/12 was written by the Registered Nurse (RN). The order was not timed. The physician giving the order had not yet authenticated it at the time of the review. A second telephone order for soft wrist restraints was taken by the RN on 3/31/12 and again had not been authenticated by the physician. This order was also not timed.

Review of the facility's policy "Restraint and Seclusion", #PC 336, revised 12/10 required that telephone orders for restraints be authenticated within 24 hours. It further required that if restraints are to be continued after 24 hours, the physician must assessment the patient and write the order for continuation. Telephone orders are not acceptable for restraint continuation.

Based on record review, policy review and staff interview it was determine the facility failed to ensure verbal orders were authenticated per facility policy for 2 (#3 and #12) of 12 sampled patients. This practice does not ensure safe delivery of medical care.

Findings include:

The facility's policy "Physician Orders-Use Of" # 1103, required that telephone orders be authenticated within 24 hours.

1. Review patient #3's medical record on 4/5/12 at approximately 11:10 a.m. revealed a telephone order taken by a Registered Nurse on 3/29/12 at 4:43 p.m. for Procardia XL. Another telephone order for bed rest, Lexis stress test and nothing by mouth after midnight was taken by the nurse on 4/2/12. The orders had not been authenticated by the physician.

The Director of Quality who was present during the review confirmed the findings.

2. Patient #12's medical record revealed a telephone physician order was taken by the nurse on 2/27/12 at 3:20 p.m. and 5:45 p.m. The orders were not authenticated until 3/14/11. The discharge order was taken as a telephone order on 3/1/12 at 1:25 p.m. The order was not authenticated by the physician until 3/14/12. An order sheet entitled Admission Orders Gastrointestinal Bleed was documented as a telephone order with no date or time and was not authenticated until 3/11/12. The medication reconciliation admission form that indicated which medications were to be continued in the hospital was documented as a telephone order with no time indicated and was not authenticated until 3/14/12.

The Nursing Director who was present during the record review on 4/5/12 at approximately 12:45 confirmed the findings.

Based on record and policy review it was determined the facility failed to ensure an appropriate History and Physical was in place prior to an endoscopic procedure for 1 (#11) of 12 patients. This practice does not ensure up to date patient information is available.

Findings include:

Patient #11 was admitted to the facility on 11/2/11 for an outpatient endoscopic procedure. Review of the medical record revealed a History and Physical that had been dictated in the physician's office. There was no documentation of the date the examination was performed.

Review of the facility's policy a "History and Physical Documentation in the Medical Record" # 224, reviewed 12/11 required that the History and Physical be no more than 30 days before admission. There was no way to determine how old the History and Physical was.

Based on document review and staff interview it was determined the facility failed to ensure unauthorized individuals did not gain access of patient information. This practice does not ensure confidentiality, privacy, and security of information.


Finding include:

The Risk Manager was interviewed on 4/5/12 at approximately 1:30 p.m. She indicated that on January 2, 2012 she had been notified by a former employee that a form containing patient names and other personnel information had been given to her with a packet of her own medical records from an outpatient procedure performed on 12/30/11.

The Risk Manager indicated an investigation had taken place. The Risk Manager and Director of Registration learned the form listed 81 patients scheduled for procedures along with their date of birth, social security and other demographic information had inadvertently been left on a printer. The printer was used by all registration personnel. The form was picked up by a scheduler as she prepared a packet of medical records for the patient.

The Risk Manager presented evidence that the registration department staff was instructed to carefully review each page of records given to patients to ensure only information pertinent to the patient was included. A meeting for all facility directors was held to discuss the breach on 1/12/12. Each director instructed their employees not to leave any patient information on printers in their areas. The form now only prints to the secure printer.

The staff did not present any evidence of a quality monitor in place to determine that the actions taken have been effective in preventing a breach in the future.