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NORTH SHORE MEDICAL CENTER - 81 HIGHLAND AVENUE SALEM, MA 01970 Dec. 17, 2019
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on document review and interviews, the Hospital failed for five (Patient #1, #3, #6, #8, #10) patients out of ten patients sampled to ensure its nurses abide by federal regulations and Hospital policy to minimize the use of verbal orders.

The policy titled "Verbal /Telephone Orders," last revised 12/2018, states that: "In accordance with relevant state and federal regulations, and Joint Commission standards, the use of verbal orders must be minimized and therefore, are only appropriate in specific patient care situations. Verbal orders may only be accepted in emergency or life-threatening patient care situations, or when time is of the essence and a delay in implementation of the order would have the potential to cause significant harm to the patient." The policy goes on to state, "The Licensed Independent Practitioner (LIP) must authenticate the verbal order promptly by either signing the order or entering his/her electronic key."

The Surveyor identified that the above policy was in place prior to Patient #1's medication errors that occurred on 11/27/2019. Nurse #1 was responsible for the care of two patients with the same last name in the behavioral health section of the Emergency Department (ED). Nurse #1 entered the wrong medications (intended for another patient) into the electronic medical record system for Patient #1 and also administered these medications in error to Patient #1.

During an interview on 12/16/19 at 11:50 A.M. Nurse #1 said that she was overseeing care on two patients with the same last name and rooms adjacent to each other. Nurse #1 said that nurses will enter orders on behalf of the physician and then, at times, may administer medications prior to co-signature. Nurse #1 said she entered medications for both of her patients (Patient #1 was one of these patients) and Nurse #1 said she inadvertently entered the medications intended for her second patient under Patient #1 and subsequently administered four medications to Patient #1 in error. Nurse #1 said that, after one of the patients questioned one of the medications, Nurse #1 discovered she swapped the medication lists of the two patients. Nurse #1 proceeded to notify the charge nurse and the physician of the administration error. As a result, Nurse #1 said that Patient #1 was placed on increased monitoring and moved from the behavioral health pod of the ED to a medical pod.

During an interview on 12/16/19 at 12:50 P.M., the Nursing Director said that, if the medications are considered non-emergent, the physicians should be entering the orders.

During an interview on 12/16/19 at 1:45 P.M., Nurse #2 said that she enters medication orders after verifying the medication list and after having a conversation with the doctor. Nurse #2 said that it depends on the doctor and at times the doctor may enter the medication orders but sometimes the nurse will enter the medication orders as verbal orders.

During an interview on 12/16/19 at 2:00 P.M., Nurse #3 confirmed that she has entered verbal orders for non-emergent medications. In terms of frequency, Nurse #3 said it varies and that some days may be more than other days.

During an interview on 12/16/19 at 2:20 P.M., Nurse #5 said that he reconciles a medication list for his patients and reviews it with the physician. Nurse #5 said that if the physician asks him to enter the medications, he will enter the medications. Nurse #5 said this process occurs on a daily basis.

The Internal Investigation, dated 12/16/19 at 11:48 A.M. states a discussion summary between the Nursing Director of the ED and Nurse #1 (Nurse #1 entered and administered the wrong medications to Patient #1). Part of the discussion summary states the following:
-Do not take verbal orders on a non-emergent patient.
-Physicians should be ordering all medications on non-emergent patients.

Record review of Patient #1 indicated four medications were entered by Nurse #1 on 11 /27/19 at 8:32 A.M. with the designation "ordering mode: per protocol: cosign required." These four medications were administered on 11/27/19 between 9:19 and 9:20 A.M. There is no indication that these medications were ever co-signed by a provider/LIP as of 12/17/2019.

Record review of Patient #3 indicated at least one medication was entered by Nurse #7 on 12/16/2019 at 12:23 A.M. with the designation "ordering mode: per protocol: cosign required."

Record review of Patient #6 indicated at least five medications were entered by four different nurses (Nurse #2, Nurse #8, Nurse #9, Nurse #10) over the course of 12/15/19 and 12/16/19 with the designation as "ordering mode: verbal with readback" or "ordering mode: telephone with readback" or "ordering mode: per protocol: cosign required" Record review indicated one of these medications was administered on 12/16/19 at 8:38 P.M. and, as of the morning of 12/17/19, did not indicate a co-signature by an LIP (greater than 12 hours after administration).

Record review of Patient #8 indicated at least two medications were entered by Nurse #11 with the designation as "ordering mode: verbal with readback" on 12/16/19 at 6:56 A.M. One medication was administered on 12/16/19 at 9:09 P.M. The second medication was administered on 12/17/19 at 8:53 A.M. Neither medication indicated co-signature by an LIP as of the time the Surveyor conducted the record review the morning of 12/17/19.

Record review of Patient #10 indicated at least two medications were entered by Nurse #2 and Nurse #12 with the designation "ordering mode: verbal with readback" and "ordering mode: per protocol: cosign required." One of the medications was entered on 12/15/19 at 10:32 A.M. by Nurse #12. The order did not indicate co-signature by an LIP as of the time the Surveyor conducted the record review (greater than 2 days after order entry, as record review was conducted the morning of 12/17/19).

Despite evidence that the Nursing Director (through interview and internal investigation summary notes) indicated that nursing staff should not be taking verbal orders for non-emergent patients, and in addition, Hospital policy that dictates that verbal orders may only be accepted in emergency or life-threatening patient care situations, multiple nurses have continued to take verbal orders from physicians. Failure of staff to adhere to the "Verbal/Telephone Orders" policy can potentially lead to another significant re-occurrence, increasing risk of harm to the Facility's patients.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interviews, the Hospital failed for five (Patient #1, #3, #6, #8, #10) patients out of ten patients sampled, to ensure its nurses abide by federal regulations and Hospital policy to minimize the use of verbal orders.

See tag A-0407