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Based on medical record review and interviews, the facility failed to ensure verbal orders were signed and verified by the ordering physician in 12 out of 22 medical records reviewed (Patients #1, #4, #5, #6, #9, #11, #12, #13, #15, #18, #21, and #22). In addition, medical record review also revealed 2 out of 22 patient records (Patients #7 and #19) had verbal orders that were not verified and signed by the physician within appropriate time frames defined by the facility.

This failure created the potential for patient orders to be administered without the supervision of an authorized ordering provider.

FINDINGS

POLICY

According to the policy, Verbal Orders, prescribers should verify, sign, and date orders within 24 hours.

REFERENCE

According to the Medical Staff Bylaws Rules & Regulation, the physician shall countersign all orders when they have been recorded either verbally, or by telephone, by other health care professionals.

1. The facility failed to ensure that qualified ordering providers were countersigning, or validating, orders after issuing a verbal order to nursing staff. The facility also failed to ensure that ordering providers were countersigning all verbal orders within a timeframe defined by facility policy.

a) Medical record review for Patient #13 found that the patient arrived to the emergency department (ED) on 12/08/16 for treatment of lethargy, hypotension, and increasing shortness of breath. Review of the Physician Entered Orders Report revealed that a verbal order of Rocephin (an antibiotic) 1 gram (gm) intravenous (IV) was entered but never verified, or countersigned, by the ordering provider, Physician #4.

b) Medical record review of Patient #9, admitted for further evaluation of flank pain and nausea, revealed verbal orders missing authentication signatures from the ordering provider. Review of the Physician Entered Orders Report revealed verbal orders entered on 04/25/17 for Coumadin (a medication used to treat blood clots) 10 mg and Hydromorphone (a narcotic pain medication) 1 mg IV. Both verbal orders were missing the required follow-up signatures for verification from the ordering provider, Physician #4.

c) Medical record review for Patient #15, who arrived via EMS after a motor vehicle accident with subsequent loss of sensation in the left lower extremity, revealed unsigned verbal orders by the ordering provider. Review found that a verbal order entered on 06/23/17 for a computerized tomography (CT) scan of the head or brain without contrast was without a cosigning verification signature by the ordering provider, Physician #4.

d) Medical record review for Patient #19, admitted on 05/24/17 for further evaluation of abdominal pain, revealed verbal orders unsigned in a timely manner by the provider. Review of the Physician Entered Orders Report revealed a verbal order of Ativan (an anxiety medication) 0.5 milligrams (MG) IV at bedtime and Hydromorphone 0.5 mg IV every 6 hours as needed were entered on 05/24/17 but were not signed, or authenticated, by the ordering provider Physician #3 until 06/29/17 (36 days later).

e) On 07/07/17 at 1:17 p.m., an interview was conducted with the Director of Nursing (Director #1) who reviewed the medical records and confirmed that verbal orders entered by registered nurses were not consistently countersigned and verified by the ordering providers. According to Director #1, the expectation of the facility was that all verbal orders received from a physician were countersigned by the ordering provider within 24 hours. During the interview, Director #1 placed a phone call to the Health Informatics Management Director (Director #2) to determine if there were any current audit processes in place to monitor if physicians were signing verbal orders. According to Director #2's response over the phone, no one in the facility was routinely reviewing patient records to monitor if physicians were countersigning all verbal orders.

f) On 07/07/17 at 9:10 a.m., an interview was conducted with the Medical Director (Physician #3) who was able to confirm that verbal orders were not always cosigned, or verified, in a timely manner. During the interview, Physician #3 identified lack of time and technical computer issues as barriers to timely follow-up verification signatures for verbal orders. Physician #3 stated that lack of verification signatures for verbal orders was a valid concern, because without verification signatures s/he could not be certain all of the facility's ordering providers were following up and verifying verbal orders appropriately.