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Based on observation, interview and record review, the facility failed to ensure verbal orders received by licensed nurses are signed by the Physician giving orders in a timely manner and confirmation signatures of the Physician for psychotropic drugs consents were obtained for in 2 of 10 sampled patients. Patient #s 1, 2


Findings:
Review of the facility's current policy and procedure on informed consent Medications/ Psychoacive Policy # 3137677 direct staff as follows:" On admission the LPN, RN, MD, or RPH will meet with the patient and discuss the medications including their admission orders. All prescribed medications should be discussed with the patient. No medication should be administered to the patient until informed consent has been obtained. Informed consent is received for each newly medication. Ideally, the ordering physician will discuss the medication before ordering."

Review of Patient # (1's) clinical record (discharged record) revealed Physician's orders for medication and restraint.

Review of the Patient's clinical record revealed the following orders by the Patient's Attending Physician:
02/02/2018 001: Verbal order "Ativan 0.5 mg/ IM Q4 hours for increased anxiety and restlessness."
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/02/2018 22:35: Telephone order: "May restrain for I minute in order to administer therapeutic medication. Ativan 0.5 mg IM to decrease severe agitation."
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/03/2018 0000: Telephone order "May restrain for I minute in order to administer therapeutic medication: Ativan I mg with Haldol 2 mg IM to decrease severe agitation. "
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/04/2018: Telephone Order: "Ativan 0.5 mg with Haldol 2 mg IM, PRN severe agitation."
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/04/2018: 1355: Telephone order: "May restrain for I minute in order to administer therapeutic medication: Ativan 0.5 mg with Haldol 2 mg IM to decrease severe agitation. "
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/04/2018 3:00 p.m: "May restrain pt for one minute to give therapeutic medication. Ativan 0.5 mg IM to decrease agitation. "
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

02/07/2018: Telephone order: "L hip joint W/oblique x-ray today, HX of fall."
Review on 02/22/2018 of the Patient's clinical record revealed the order was not signed by a physician.

Ativan
Review of the Patient's clinical record (discharged record) revealed signed consent for treatment dated 02/01/2018 for psychotropic medication of Ativan. The consent was signed by the Patient's legal representative and a Facility's Registered Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation."
Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

Risperdal
Review of the Patient's clinical record ( discharged record) revealed signed consent for treatment dated 02/01/2018 for psychotropic medication of Risperdal. The consent was signed by the Patient's Legal Representative and a Facility's Licensed Vocational Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation." Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

Depakote
Review of the Patient's clinical record ( discharged record) revealed signed consent for treatment dated 02/01/2018 for psychotropic medication of Depakote. The consent was signed by the Patient's legal representative and a Facility's Licensed Vocational Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation."
Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

Haldol
Review of the Patient's clinical record ( discharged record ) revealed signed consent for treatment dated 02/01/2018 for psychotropic medication of Haldol. The consent was signed by the Patient's legal representative and a Facility's Registered Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation." Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

Review of the Patient's clinical records ( discharged record) revealed the following physician's orders dated 02/08/2018:
"Fosamax 70 mg Q wed at 0700
Norvasc 5 mg daily PO
Lipitor 40 mg Q day PO
Coreg 3.125 mg BID PO
Depakote delayed 500 mg 1,500 MG QHS PO
Haldol 5 mg/ml Q4 h PRN IM
Synthroid 25 mcg PO
Imodium 2 mg Q6 h PRN Loose Stool
Namenda 10 mg BID PO
Protonic 40 mg BID PO
Risperdal 2 mg QHS PO
Risperdal 1mg QHS PO
Review on 02/22/2018 of the Patient's record revealed the order was not signed by a physician.


Patient #2
Ativan /Haldol
Patient #2 was observed on 02/22/2018 at 11:00 a.m. on the Senior care unit of the facility in group therapy. The Patient was calm and responsive.

Review of Patient #2's clinical record revealed the following orders by the patient's Attending Physician:

02/16/2018 001: Telephone order "May restrain PT for one minute in order to give Pt therapeutic medication Ativan 1 mg/ Haldol 2 mg IM to decrease agitation and psychotic symptoms'"

Review on 02/22/2018 of the Patient's record revealed the order was not signed by a physician.

02/18/2018 2100; Telephone order "Give Ativan 1mg with Haldol 2 Mg for agitation IM "
Review on 02/22/2018 of the Patient's record revealed the order was not signed by a physician.

Review of Patient #2's clinical record, revealed signed consent for treatment dated 02/15/2018 for psychotropic medication of Ativan. The consent was given by the Patient's son via the telephone and signed a Facility's Registered Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation."

Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

Haldol
Review of Patient#2's clinical record revealed signed consent for treatment dated 02/17/2018 for psychotropic medication of Haldol Po/ IM. The consent was given by the Patient's son via the telephone and signed a Facility's Registered Nurse.

Review of the consent revealed the following documentation: "Confirmation Signature of Treating Physician to confirm explanation given by Pa, CNC, RPH, RN, or LVN. Is required within two days of PA, CNS, RPH, RN, or LVN giving explanation."

Review of the consent revealed the Confirmation Signature of Treating Physician was missing from the consent.

On 02/22/2018 at 12:30 p.m., the Surveyor reviewed the Patient's clinical record with the Facility's Senior Care Unit Nurse Director. She confirmed that the telephone and verbal orders were not signed by the physician.