HospitalInspections.org

A. Based on medical record review and staff interview it was determined that in 3 of 21 (Patient (Pt.) #16, 17, 20) records reviewed, the Critical Access Hospital (CAH) failed to ensure that physician orders were complete and accurate.

Findings include:

1. The medical record of Pt. #16 was reviewed on 10/7/09. Pt. #16 was admitted to the CAH on 8/18/09 with the diagnosis of Anemia. Documentation indicated that admission orders were written on 8/18/09 and signed by the physician on 8/19/09 with no time. Documentation indicated that a physician order for "CT of abdomen..." was written on 8/18/09 and signed by the physician on 8/19/09 with no time.

2. The medical record of Pt. #17 was reviewed on 10/7/09. Pt. #16 was admitted to the CAH on 8/3/09 with the diagnoses of Hepatocellular Carcinoma and Hypertension. Documentation indicated that a physician order "Sonogram liver, GB...) was written and signed on 8/4/09 with no time. Documentation indicated that on 8/4/09 the Deep Vein Thrombosis (DVT) prophylaxis was signed and dated by the physician with no time.

3. The medical record of Pt. #20 was reviewed on 10/7/09. Pt. #20 was admitted to the CAH on 7/17/09 with the diagnoses of Fractured Right Femur and Right Hip Pain. Documentation indicated that a physician order "Admit pt. to Med-Surg..." written on 7/17/09 with no time.

4. During an interview with the Director of Patient Care Services on 10/8/09 at 12:00 PM, the above findings were confirmed.