HospitalInspections.org

Based on record review, interview and policy review, the Critical Access Hospital (CAH) failed to ensure a physician's signature was on all orders, verbal and written in 4 of 20 medical records reviewed (Patient #1, #7, #13, and #17). Failure of the CAH to ensure all orders are signed by the ordering provider put all patients at risk of receiving unsafe care.

Findings Include:


Patient #1's medical reviewed on 3/29/2017 at 4:00 PM revealed the patient was an emergency department patient with a diagnosis of a first-degree burn to the left arm on 3/19/2017. The medical record revealed the facility failed to ensure medication orders were signed by the physician as required per hospital policy.

Patient #7's medical record reviewed on 3/30/2017 at 10:00 AM revealed the patient was an emergency department patient with a diagnosis of right sided musculoskeletal pain on 3/26/2017. The medical record revealed the facility failed to ensure medication orders were signed by the physician as required per hospital policy.


Patient #13's medical record review on 3/30/17 at 10:00 am reveals the patient, 78 years old, was seen in the emergency department (ED) on 3/21/2017 with complaints of lost suture from previous surgical incision. The medical record revealed the facility failed to ensure medication orders were signed by the physician as required per hospital policy.


Patient #17's medical record review on 3/30/2017 at 10:00 am reveals the patient, 62 years old, was seen in the ED on 3/25/2017 with complaints of severe headache and requesting pain relief. The medical record revealed the facility failed to ensure medication orders were signed by the physician as required per hospital policy.


Pharmacy Staff D acknowledged "When a medication is entered into the Pyxis system (an automated medication dispensing system supporting decentralized medication management. It helps clinicians safely and efficiently dispense medications while offering enterprise-ready integration) and the medication is removed, the electronic Pyxis system and the electronic medical record (EMR) will automatically show that action in the EMR. Evidently that does not automatically send it into the ordering physicians' queue for signature of the order. That may be a simple fix in the EMR system. I will see if I can track that. If not, we will send in a fix it ticket to our EMR provider to fix, so that all medication orders are signed from this point forward."

"Medical Record Completion" policy reviewed 3/30/2017 directs " ...No record shall be considered complete until the appropriate signatures are obtained ... ...Electronic orders and reports will be electronically signed by the provider ..."