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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.24 Medical Record Services was out of compliance.

A-0431 MEDICAL RECORD SERVICES The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. Based on record review and interviews the facility failed to ensure provider orders were signed in 6 of 14 patient medical records reviewed (Patients #2, #3, #6, #8, #11, and #12).

Based on record review and interviews, the facility failed to ensure provider orders were signed in 6 of 14 patient medical records reviewed (Patients #2, #3, #6, #8, #11, and #12).

Findings include:

Facility policy:

According to the facility policy Medication Administration, An order is required before administration of any medication. The order should be written and signed on the physician's order sheet by the physician/practitioner. Telephone medication orders should be written out and read back to the physician/practitioner to avoid medication errors. The physician/practitioner should sign the phone, verbal, or electronic order upon his/her return to the hospital.

1. The facility failed to ensure orders were countersigned by providers.

A. Medical Record Review

i. A review of the medical records of Patients #2, #3, #6, #8, #11, and #12 was conducted on 10/17/22 and 10/18/22 and revealed orders that were not signed by the provider who originated the order. Examples included:

a. The review of Patient #2's medical record revealed telephone orders with readback (telephone orders) that had not been signed by a provider (nurse practitioner or physician). For example, on 8/21/22 a handwritten telephone order for a medication lacked a provider's signature. Also on 8/21/22, a preprinted admission order set was not signed by a provider.

b. The review of Patient #3's medical record revealed telephone orders, physician detox orders, and admission orders that had not been signed by a provider. For example, on 8/26/22 a handwritten telephone order for medication changes lacked a provider's signature. On 8/23/22 a preprinted detox order set was not signed by a provider. On 8/22/22 a preprinted admission order set was not signed by a provider.

c. The review of Patient #6's medical record revealed admission orders that had not been signed by a provider. For example, on 8/19/22 a preprinted admission order set was not signed by a provider.

Similar findings of orders not verified by a provider's signature were found in the medical record reviews of Patients #8, #11, and 12.

These findings were in contrast to the facility policy Medication Administration, which required telephone medication orders to have been written out and read back to the physician or practitioner to avoid medication errors.

B. Interviews

i. On 10/19/22 at 12:15 p.m., an interview was conducted with Physician #4. Physician #1 stated all orders were expected to be signed by the provider, including telephone or verbal orders. The expectation was to have orders written by staff signed by the provider so the provider could verify accuracy. He further explained signing the order was important as the signature confirmed authorization of the order. Physician #1 said if an order was not signed by the provider, there would have been risk to the patient as someone could be practicing medicine without a license.

ii. On 10/19/22 at 12:51 p.m., an interview was conducted with Nurse Practitioner (NP) #5. NP #5 said orders should always be signed. She further stated this should have been done as soon as possible to verify accuracy.

iii. On 10/19/22 at 2:02 p.m., an interview was conducted with Nurse Practitioner (NP) #2. NP #2 stated all orders, including verbal and telephone orders, required a signature from the provider. She further stated staff should have contacted the provider to sign orders as soon as possible after they identified an unsigned order. NP #2 also said it was important to sign the order as it validated the order came from the provider.

iv. On 10/19/22 an interview was conducted with the Director of Quality (Director) #6. Director #6 stated all orders should have been signed by the provider. Director #6 explained if an order was not signed, a chart audit should have prompted notification to a supervisor or the provider.