HospitalInspections.org

Based on record review and interviews, the facility failed to ensure the implemented nursing plan of care was consistent with the physician orders: the physician orders were not followed for one of ten patient clinical records reviewed, Patient #1, related to ensuring the ordered radiology scan was completed on 12/23/11.


The findings include:

Interview with the Chief Nursing Officer on 4/10/2012 at approximately 9:38 AM revealed the facility has adopted the Lippincott Manual as their standard of practice which included following physician orders. She verbalized the policy is for nurses to follow physician orders. Further interview with the Director of Quality Assurance (QA), the Nurse Manager of Telemetry and the Computer Provider Order Entry (CPOE) Registered Nurse on 4/12/2012 at approximately 4:12 PM revealed it is the expectation that nurses follow physician orders as per the policy.

Review of the physician order for Patient #1 of 12/23/2011 at 1:38 PM, revealed the physician ordered a routine (not STAT) "MRI of the brain with - without contrast". Review of the record revealed a CT scan of the brain was completed, and not the MRI. Interview with the Nurse Manager of Telemetry, the Director of Quality Assurance (QA) and the RN Computer Provider Order Entry (CPOE) on 4/10/12 at approximately 4:10 PM and again on 4/11/12 at approximately 4:30 PM, revealed they believe the secretary hit the "CT scan" button instead of the MRI button when scheduling the procedure. They all agreed the MRI was ordered (and as per record review) and the CT scan was completed. The physician reordered the routine MRI on 12/24/11 but later canceled it on 12/26/11.