HospitalInspections.org
Bringing transparency to federal inspections
CALHOUN-LIBERTY HOSPITAL
RECORDS SYSTEM
Tag No.: C1118
Based on record reviews and interviews, the facility failed to have verbal orders authenticated by the ordering providers for 5 of 11 patient records reviewed with verbal orders (patients #4, #9, #10, #11, and #15).
The findings include:
On 3/11/20 a record review was conducted for patient #9, admitted on 1/2/20 and discharged on 1/4/20, showed a total of 4 verbal medication orders pending ordering physician signature to authenticate the order.
On 3/11/20 a record review was conducted for patient #10, who was admitted as an inpatient on 1/7/2020 and discharged on 1/13/2020, and had a total of 6 telephone orders which were noted as pending signatures.
On 3/11/20 at approximately 12:00pm, staff A, a registered nurse (RN), stated during record review that the provider's signature appeared to still be pending. Staff A compared the electronic order documentation to other orders in the electronic system and discovered that some were marked as signed, but the verbal orders for patients #9 and #10 indicated the signature was still pending.
41401
On 3/11/20 a record review was conducted for #4, admitted on 1/3/2020 and discharged on 1/6/2020, showed a total of 3 verbal medication orders pending ordering physician signature to authenticate the order.
On 3/11/20 a record review was conducted for #11, admitted 2/24/2020 and discharged on 2/28/2020, showed a total of 4 verbal medication orders pending ordering physician signature to authenticate the order.
On 3/11/20 a record review was conducted for #15, admitted 1/23/2020 and discharged on 1/24/2020, showed a total of 17 verbal medication orders pending ordering physician signature to authenticate the order.
On 3/11/2020 at approximately 1:23 PM during interview with the facility Medical Director, the Medical Director was unable to demonstrate where it could be verified in the electronic medical record that the verbal orders had been authenticated. The Medical Director explained that the system would prompt him to authenticate it if needed but was unable to show where evidence that the orders had been signed or authenticated.
On 3/12/2020 at approximately 2:15 PM during interview and record review with the Unit Manager and the facility Chief Nursing Officer, neither were able to demonstrate where it could be reviewed that the verbal orders had been authenticated by the prescribing physician.