HospitalInspections.org

The Hospital identified a census of 10 inpatients and 20 records were reviewed (10 inpatient and 10 closed records). Based on record review, document review and staff interview for 8 of 20 records reviewed, the Hospital failed to ensure verbal orders given infrequently. (#20,16, 3, 2, 18, 4, 14, and 15)

Findings included:

- Review of the medical records revealed multiple instances where Hospital Physician's gave verbal orders to another licensed staff member to write for them when the Physician was present and capable of writing their own orders in the medical record.

Review of the physician orders for patient #20, between 11/3/09 and 1/4/10, revealed Physician N gave verbal orders on 11/3/09 at 7:00am and also on 11/4/09 at 7:27am. to licensed nurse C.

Review of the physician's orders for patient #16, between 1/2/10 and 1/4/10, revealed verbal orders written for Physician O on 1/2/10 at 7:45am., 8:35am, and 6:50pm, and on 1/4/09 at 6:50am.

Review of the physician's orders for patient #3, between 12/30/09 and 1/4/10, revealed verbal orders written for Physician O on 12/30/09 at 2:50pm., 1/4/10 at 5:30am. and for another untimed order on that same date.

Review of the physician's orders for patient #2, between 12/28/09 and 12/31/09, revealed verbal orders written for Physician O on 12/28/09 at 2:00pm. (the patient's entire swing bed admission order set), and also another order on 12/28/09 (untimed), on 12/30/09 at 7:18am and on 12/31/09 at 7:24am.

Review of the physician's orders for patient #18, between 12/16/09 and 12/19/09 revealed verbal orders written for Physician P on 12/16/09 at 9:40am. and 11:00am., 12/17/09 at 9:15am, and 12/18/09 at 7:25am.

Review of the Physician's orders for patient #4, between 11/30/09 and 12/1/09 revealed verbal orders written for Physician O on 11/30/09 at 6:45am., 6:56am. and 9:00am, and on 12/1/09 at 6:20am. and another unidentified time.

Review of the Physician's orders for patient #14, between 1/1/10 and 1/4/10, revealed verbal orders written for Physician O on 1/3/10 at 8:00am. and 6:00pm, and 1/4/09 at 7:00am.

Review of the Physician's orders for patient #15, between 12/30/09 and 1/3/10, revealed verbal orders written for Physician O on 12/31/09 at 7:29am, 1/3/10 at 8:00am. and 1:00pm

Review of the facility Medical Staff Rules and Regulations, provided on 1/5/10 at 11:02am. revealed the Rules and Regulations failed to address verbal orders and provide parameters for regulating the use of that type of order. Other policies provided at that time also failed to address the need to keep verbal orders to a minimum.

Licensed Nurse Q, on 1/4/09 at 1:05pm., verified the facility used 2 nurse "associates", which were Registered Nurses currently in school to become Nurse Practitioners. They stated these Nurse Associates rounded with Physician's and wrote the orders given to them by the Physician at the time and then gave the chart to the Physician to sign after them.

Interview with Licensed Registered Nurse "Associate" staff member C, on 1/4/09 at 1:17pm and 1:22pm verified they rounded with the Physician's and wrote the verbal orders while the Physician was present and capable to do so themselves and then handed the chart to the Physician to sign after them.

The Hospital identified a census of 10 inpatients and 20 records were reviewed (10 inpatient and 10 closed records). Based on record review, document review and staff interview for 8 of 20 records reviewed the facility failed to ensure clinical records documented accurately. (#20, 16, 3, 2, 18, 4, 14, 15)

Findings included:

- Review of the facility Medical Staff Rules and Regulations, provided for review on 1/5/10 at 11:02am. revealed the following "...26...Physician will authenticate orders within 24 hours of ordering..."

Review of the physician orders for patient #20, between 11/3/09 and 1/4/10, revealed Physician N signed 5 orders given to another licensed staff member to write, but failed to document the time and date of this authentication.

Review of the physician's orders for patient #16, between 1/2/10 and 1/4/10, revealed Physician O signed 7 orders given to another licensed staff member to write, but failed to document the time and date of this authentication. A "Do not resuscitate" order written by this physician on 1/4/10 also lacked the time physician wrote the order.

Review of the physician's orders for patient #3, between 12/30/09 and 1/4/10, revealed the licensed Speech Therapist R failed to time their order for thin liquids for this patient.

Review of the physician's orders for patient #2, between 12/28/09 and 12/31/09, revealed Admission orders to Swing bed which included a soft diet. Written on this same line, but in a different handwriting, was the order for a 2000 calorie American Dietetic Association diet. The person writing this clarification into the orders failed to identify themselves as the author and interview with staff member C, on 1/4/10 at 1:17pm. verified they wrote the balance of the orders and verified this clarification piece was not their handwriting and not written by them. Two of the orders in this record, co-signed by Physician O lacked the date and time of this authentication. Another order written by Respiratory Therapist D, on 12/28/09 lacked a time of the order and the physician's order on 12/31/09 at 7:24am. was noted by the Ward Clerk S, who wrote their initials over the signature line obscuring the documentation of whether this was a telephone or a verbal order.

Review of the physician's orders for patient #18, between 12/16/09 and 12/19/09 revealed an order on 12/16/09 at 11:00am. where Ward Clerk S signed their initials over documentation of the Physician giving the orders making this unreadable. Physician's orders on 12/18/09 at 8:56am written by Physician P, contained an order for Klor-Con. This line also contained the words "20 MEQ PO daily", in different handwriting than the Physician's handwriting. On 1/5/10 between 1:00 and 2:20pm interviews with Licensed staff members Tand A, verified lack of knowledge who wrote the strength and frequency of the Potassium order into the medical record.

Review of the Physician's orders for patient #4, between 11/30/09 and 12/1/09 revealed an Insulin Sliding scale order sheet with orders for glucose monitoring and insulin type and sliding scale filled in by the Physician, but with the patient's diagnosis and diet order completed by someone else (as noted by the very different handwriting). The only signature on the order sheet belonged to the Physician and the person ordering the diet failed to authenticate their entry into the orders.

Review of the Physician's orders for patient #14, between 1/1/10 and 1/4/10, revealed 8 telephone and verbal orders authenticated by Physician O which lacked the date and time of the authentication.

Review of the Physician's orders for patient #15 revealed an order dated 12/30/09 at 12:50pm where facility ward clerk S wrote over part of an order with their initials.

Review of policies provided by the facility failed to instruct Physician's to time and date when they sign their verbal and telephone orders, failed to instruct staff that after the orders were written, any further clarifications needed to be in a separate entry, and failed to instruct staff to not write over others writing in the orders thereby making them unreadable.