HospitalInspections.org

Based on review of facility policy , medical records, and staff interview, it was determined the facility failed to ensure that oral orders were authenticated by the physician/provider for 5 out of 10 medical records reviewed (MR1, MR2, MR3, MR4 and MR5).

Findings include:

A review of facility policy "Orders, Physician, revised 04/01/18...Procedure:...D. Authentication: the responsible practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate, time and date all orders promptly, within the time frame specified by state law, including scope-of practice laws, hospital policies and no later than 30 days after discharge..."

A review of MR1 revealed a "Patient Care Timeline (This is the documentation of the Patient Code). The patient was found unresponsive on July 15, 2018, and required resuscitation. The patient received Epinephrine (a hormone, neurotransmitter, and medication), sodium bicarbonate (used to combat acidosis) and naloxone (an opioid antagonist) as part of the resuscitation efforts. The review of the medical record did not reveal that the orders for the medications given during the code had been authenticated by the physician.

The review of MR2 revealed a "Patient Care Timeline." The patient received medication during resuscitation efforts on June 6, 2018. The patient received Epinephrine (a hormone, neurotransmitter, and medication) as part of the resuscitation efforts. The review of the medical record did not reveal that the orders for the medication given during the code had been authenticated by the physician.

The review of MR3 revealed a "Patient Care Timeline." The patient received medication during resuscitation efforts on May 29, 2018. The patient received Epinephrine (a hormone, neurotransmitter, and medication) and Calcium gluconate 10 % (Management of cardiac arrest in presence of hyperkalemia, hypokalemia, or hypermagnesemia) as part of the resuscitation efforts. The review of the medical record did not reveal that the orders for the medication given during the code had been authenticated by the physician.

The review of MR4 revealed a "Patient Care Timeline." The patient received medication during resuscitation efforts on May 24, 2018. The patient received Epinephrine (a hormone, neurotransmitter, and medication), sodium bicarbonate used to combat acidosis), phenylephrine (Neo-Synephrine) ( a vasopressor), Norepinephrine Bitartrate (Levophed) (functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries) and atropine (drug used for bradycardia). The review of the medical record did not reveal that the orders for the medication given during the code had been authenticated by the physician.

An interview conducted on August 2, 2018 at 9:00 AM with EMP1 revealed that the "Patient Care Timeline" was the place where the physician orders for medications were entered. The Physician uses an electronic signature after the code to authenticate the orders. Further interview confirmed that the orders were not authenticated by the provider for MR1. MR2, MR3, MR4, and MR5.