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Based on review of documentation, it was determined that the Governing Body failed to enforce the hospital ' s own policies and procedures.

Findings were:

Facility policy entitled " Prerequisite to Administration " stated " Medication Administration Record shall be checked for completeness and accuracy. When medications are administered, they must be signed and initialed on the MAR. "
The same policy further stated, " Medication errors are to be reported on the occurrence form. Person discovering the discrepancy initiates the report. The MAR should reflect medicine given. Do not chart ' Incident report filed. ' The Pharmacy and the Physician should be notified. "

Facility policy entitled " Management of High Risk Medications " stated " Triumph Hospital has identified the following medications as high risk:
? Morphine Injection
? Insulin
? Heparin
Insulin will further require a " witness " to verify type and amount prior to the nurse injecting into a patient. "

Facility Policy entitled " Physician Requirements " stated, " All verbal/telephone orders must be dated, timed and authenticated within 48 hours. " The same policy continued, " Any dictation done by an allied health professional for a physician must be signed by the author and the physician for whom the dictation was done. "

Review of the following medical records on 1/27/11 revealed:

? Patient # 1-unsigned MD orders dated 12/16/10, 12/20/10 and 12/21/11 were found in the patient medical record. Unsigned dictated Physician Progress notes dated 1/1/11, 1/2/11, 1/3/11, 1/4/11, 1/5/11, 1/6/11, 1/21/11, 1/22/11, 1/23/11, 1/24/11, 1/25/11 and 1/26/11 were also noted in the medical record.
? Patient # 3-this patient ' s Medication Administration record dated 1/27/11 indicated that he had been given 4 units of Regular Insulin at 07:30 AM. At 8:45 AM there was no co signature in the Medication Administration Record. Staff member # 1 (RN) who had administered the Insulin stated, " I had someone at the nurses station double check the Insulin before I gave it. "
? Patient # 4-2 unsigned MD orders dated 1/11/11 and 3 unsigned MD orders dated 1/12/11 were found in the patient record. Unsigned Physician Progress notes dated 1/15/11, 1/23/11 and 1/26/11 were also found.
? Patient # 5-Unsigned Physician Progress notes dated 1/16/11, 1/22/11 and 1/23/11 were found in the patient record.
? Patient # 6-Unsigned MD orders were found in the patient record for the following dates: 1/17/11 (2), 1/25/11. Unsigned Physician Progress notes dated 1/23/11 and 1/26/11 were found as well as an unsigned Consultation Report dated 1/11/11.
? Patient # 9-this patient ' s Medication Administration Record dated 1/01/11, showed that at 12AM she was given 4 units of Regular Insulin with no co signature. On that same date, Insulin was administered at 6AM without a co signature. On 1/02/11, Patient # 9 ' s insulin was administered at 12AM and at 6AM. The MAR was initialed by only one nurse. On 1/07/11, the patient had Insulin administered at 9 PM. Again, only one nurse initialed the MAR. On 1/09/11 the MAR indicated that Insulin was given at 9PM with only 1 nurse ' s signature. On 1/10/11 at 12AM, Insulin was administered with no co signature on the MAR. Only one signature was found on the MAR on 1/18/11 for the Insulin administered at 9 PM. 1/20/11 showed an accucheck registering a blood sugar of 156. Doctor ' s orders specify that 2 units of Regular Insulin should have been given for a blood sugar between 141 and 170. The MAR indicated that Patient # 9 was given 3 units of insulin. The MAR was cosigned by 2 nurses. There was no indication that an ' Occurrence Report ' was filed for this incident.
? Patient # 7-on 1/15/11 at 8 AM and 4:30 PM, the patient was given Insulin. Only one signature was found on the MAR. On 1/18/11, Insulin was administered at 8 AM. Only one signature was found on the MAR.
? Patient # 8-this patient ' s MAR dated 1/24/11 showed that at 6 PM 6 units of Insulin was given. Only one signature was noted.
? Patient # 10-on this patient ' s MAR dated 1/19/11, there is a MD order that read, " Nitroglycerin Patch 0.4mg to be removed at bedtime. " There is no documentation to indicate that the patch had been removed. On that same day, Insulin was administered at 9 PM. No co signature was found in the MAR. On 1/20/11, Insulin was administered at 9 PM. Only one signature was found in the MAR. On 1/21/11, Insulin was administered at 7:30 AM, 11:30 AM, 4:30 PM and at 9 PM. There were no co signatures on the MAR for any of these times. On 1/23/10, Insulin was administered at 9 PM. No co signature was found on the MAR. On 1/25/11 and 1/26/11, there was no documentation in the MAR to indicate that the Nitroglycerin patch was removed at bedtime as ordered. On 1/26/11, Insulin was administered at 9 PM. No co signature was found in the MAR.

In an interview with the Chief Clinical Officer on 1/27/11, the above discrepancies were acknowledged. It was confirmed that the facility ' s medical staff were not following policy and procedures in the above documented evidence.

Based on review of documentation, it was determined that the facility failed to ensure that telephone/verbal orders were dated, timed and authenticated with in 48 hours by the prescriber.

Findings were:

Facility Policy entitled " Physician Requirements " stated, " All verbal/telephone orders must be dated, timed and authenticated within 48 hours. "

Review of the following medical records on 1/27/11 revealed:

? Patient # 1-unsigned MD orders dated 12/16/10, 12/20/10 and 12/21/11 were found in the patient medical record.
? Patient # 4-2 unsigned MD orders dated 1/11/11 and 3 unsigned MD orders dated 1/12/11 were found in the patient record.
? Patient # 6-Unsigned MD orders were found in the patient record for the following dates: 1/17/11 (2), 1/25/11

In an interview with the Chief Executive Officer and the Chief Clinical Officer on 1/27/11, it was acknowledged that the facility ' s Physicians did not always sign their verbal orders in a timely fashion.