HospitalInspections.org

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Based on medical record review, document review, and interview, in one (1) of (5) medical records reviewed the facility failed to ensure all verbal orders were documented and its policy on downtime documentation was implemented. Specifically, the facility failed to document a verbal order for chemical and physical restraints for Patient #1 that occurred during a psychiatric emergency.

Findings include:

Review of the medical record of Patient #1 revealed this 30-year-old female arrived in the Emergency Department (ED) on 11/19/22 at 10:38 PM by ambulance and was escorted by the New York Police Department (NYPD) officers. At 10:39 PM, ED Provider documented that the patient attempted to run out of the ED. When she was stopped by security, she started hitting and kicking the guards requiring chemical and physical restraint. At 11:38 PM, ED RN documented administration of Versed 4mg intramuscularly (IM).

There was no documentation of a written order for the physical restraint or the chemical restraint.

During interview on 1/31/23 at 12:00 PM, Staff A, ED RN stated: "I administered the Versed around 11:00 PM ...I leave at 12:00 AM. I got the patient late at night ...It was a verbal order. They were supposed to put it on paper because the computer was down."


Staff E RN, Director of Nursing Informatics assisted surveyor to search in the medical record for the restraint and medication orders and nursing notes of restraint event. Staff E was unable to locate documentation of the orders or nursing notes for Patient #1.

Review of facility policy titled "Verbal Orders" last reviewed 03/2021 states:
Policy 5. The verbal order must be documented into the "Verbal Order" note in the EMR (excludes code 99 where documentation is done on the "Cardiopulmonary Resuscitation flowsheet" and Code 66 MET Code) and must include the name of the patient, the date, time and name of the ordering practitioner and the name of the person writing/entering the order and implementing the order. Verbal medication orders will include the following information:
Date and time order is received
Patient name
Drug name
Dosage (for medication both parties will include the mg/ kg dose along with the patient's specific dose for all verbal neonatal/pediatric medication orders)
Route
Name of prescriber
Signature of order recipient

13. All verbal orders must be authenticated by either the ordering practitioner or another practitioner who is responsible for the care of the patient and who is authorized to write orders by hospital policy in accordance with state law. All verbal orders must be entered into the EMR by the prescribing physician immediately after the emergent situation has been resolved.


Review of facility policy titled "Emergency Department Downtime Procedures" last reviewed 03/2022 states: "...Nursing/Medication Orders are to be completed on paper forms and charts placed in the orders pending rack.
Review of facility policy titled "Downtime Escalation Procedure for Physician Order Entry" last reviewed and revised 01/2021 states: " ...
Level 1-CIS is experiencing downtime greater than 2 hours but less than 4 hours ...Physician Orders are to be written on "Doctor's Order Sheet" (Form: MR122)
All information is to be backloaded into CIS when the system is recovered such as:
Physician Orders
Nursing Care
Medications Charted
Ancillary Documentation
Staffing schedules:

Level 11-CIS is experiencing downtime greater than 4 hours but less than 48: ...
All patient orders will be written on "Doctors Order Sheet" and will become a part of the permanent Medical Record
All order entry documentation will be recorded in the Paper Medical Record.

Level 111-CIS downtime is greater than 48 hours.
Physicians must review all patient orders
All patient care orders must be written on the "Doctor's Order Sheet"
All documentation is done in the Paper Medical Record
All paper documentation and downtime reports will become a Permanent Medical Record.

Restoration of CIS/Network Services:
Upon recovery and restoration of CIS and/or Network services after downtime Level 2 and Level 3: All current orders must be entered electronically ...
When the CIS System is recovered before 5:00 PM during weekdays: All Physician Orders must be entered into CIS within two (2) hours of CIS recovery.
When the CIS System is recovered after 5:00 PM during the week, weekends, and holidays: All Physician Orders must be re-entered into CIS no later than 10:00 AM of the following day post-recovery.

At interview on 1/31/23 at approximately 12:30 PM, Staff C, Sr. Director of Health Information Management (HIM) stated: The downtime protocol goes by the time in hours. A complete paper packet gets sent to HIM. On the inpatient units, someone physically goes to the unit to pick up the paper daily. Consents, discharges get scanned into the record within 30 days.

During follow-up interview with Staff C at 2:10 PM, Staff C confirmed there were no records of physician orders.

These findings were shared with Staff B, AVP Quality Management/Regulatory Services and Staff C, Sr. Director of HIM on 1/31/23.