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STONY BROOK UNIVERSITY HOSPITAL
CONTENT OF RECORD: ORDERS DATED & SIGNED
Tag No.: A0454
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Based on document review, record review, and interview, a) the Medical Staff did not authenticate Verbal Orders within forty-eight (48) hours as per facility Policy, and b) the Nursing Staff did not document "read back" verification of Verbal Orders in the Medical Record.
Findings:
a) The facility's "Unsigned Orders by MD (Order dates: 01/28/2009 - 07/19/2017) documented that there were 221 Unsigned Orders more than forty-eight (48) hours.
On 05/11/16 at 5:22PM Staff E (Physician) verbally ordered a Calculi Analysis on Patient #19. This Verbal Order had not been authenticated by the Physician for the past 435 days.
On 08/13/16 at 7:29AM Staff F (Physician) verbally ordered a Complete Blood Count on Patient #20. This Verbal Order had not been authenticated by the Physician for the past 341 days.
On 08/15/16 at 11:13PM, 08/16/16 at 2:08AM, and on 08/16/16 at 6:53AM, Staff F verbally ordered PTTs on Patient #21. These Verbal Orders had not been authenticated by the Physician for the past 339/338 days.
The same lack of timely authentication of Verbal Orders was found in the Medical Records for Patients #22, #23 and #24 for the review period of 05/01/16 - 07/19/17.
During an interview with Staff H (Chief Medical Officer) on 07/20/17 at 3:30PM, the staff member confirmed these findings.
The facility's Policy and Procedure titled "Telephone and Verbal Orders" last revised 03/07/17, stated the following: The Verbal Orders will be "signed by the Physician within 48 (forty-eight) hours."
b) Patient #23's Medical Record identified that there was no documented evidence that a "read back" was done for a Physician's Verbal Order on 07/11/17.
The same lack of documented read back was found in the Medical Records for Patients #25 and #26.
The facility's Policy and Procedure titled "Telephone and Verbal Orders" last revised 03/07/17, stated the following: The Registered Nurse will "read back the entire order for validation".
This was confirmed with Staff I, Facility DOH Liaison, on 07/20/11 at 2:00PM.