HospitalInspections.org

Based on review of twelve (12) medical records and interview with the Director of Quality and Risk Management, the time and date written orders are "taken off" and activated by the registered nurse were omitted in twelve of the twelve records reviewed.

The findings include:
1. The physician's order sheet includes a section for the name, date and time of the practitioner writing the order. At the top of the order there is a section for the name, date and time for the nurse taking off the order and putting it into the system.
2. In twelve of twelve charts reviewed, the orders were signed by the nurse "taking off" the orders, but there was no way to determine when the order was "taken off." There was no date and time recorded for this process.
3. In a January 12, 2011 interview with the Quality Director, she said there should be a time and date to validate when the order was activated.