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Based on review of facility documentation, medical records (MR), and staff interview(EMP), it was determined the facility failed to ensure medication or treatment was administered only upon written and signed orders of a practitioner acting within the scope of his license for five of thirty-one (31) medical records reviewed, (MR 1, MR2, MR3, MR5, and MR16).
Findings include:

Review of facility policy on August 7, 2017, at approximately 11:30 AM "General Documentation Guidelines" dated August 2014, revealed, "... All orders, including verbal orders must be dated, timed and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with state law (within 24 hours), including scope-of-practice laws, hospital policies, and medical staff bylaws, rules and regulations. ..."

1. Review of MR1 on August 7, 2017, revealed that the physician provided a telephone order for labwork, pain medication and podiatry care on July 30, 2017, which was not signed by any physician.

2. Review of MR2 revealed "MR2 was admitted on July 19, 2017. The Physician Admission orders did not have the date and time the physician signed the order. Further review of MR2 revealed verbal orders taken by the RN dated 08/05/17 at 1430, 1545, 1600 and 1900 that were not countersigned by the practitioner.

3. Review of MR3 revealed "MR3 was admitted on February 17, 2017. The Physician Admission orders were not signed, dated or timed by the admitting physician. Further review of MR3 revealed verbal orders dated 02/23/17, 02/24/17, 02/26/17 at 1830 and 02/28/17 that had not been countersigned by the ordering practitioner.

4. Review of MR5 August 7, 2017, revealed that the physician provided a telephone order for labwork on August 1, 2017, which was not signed by the physician.

5. Review of MR16 on August 7, 2017, revealed that the the physician provided a telephone verbal order for a wound care treatment for MR16 on July 27, 2017, which was not signed dated or timed by the physician.

During review of the medical records on August 7, 2017, EMP8 verified the above findings related to practitioners countersigning verbal orders. EMP8 stated, "Yes, you will find that to be a problem in many of the charts. We have done extensive in-services and re-education with the nursing staff and the Medical Director has spoken with many of the offending practitioners. We flag the charts, the nurse's follow-up for signatures and we continue trying to get them to comply but it is an issue."
The facility could not provide documentation that the verbal orders listed above were countersigned by the practitioner within 24 hours.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Curahealth staff failed to ensure that necessary medical information accompanied three of four patients transferred to a higher level of care. (MR23, MR24, and MR31).

Findings include:

Review of policy on August 7, 2017, "General Documentation Guidelines", dated May 2017, revealed "Policy: To provide guidelines for the initiation and maintenance of patient care information. ...10. If a patient expires or transfers to another facility before the physician sees the patient and completed the History & Physical, a short stay summary must be completed. ... 19. The medical record for patients who receive continuing ambulatory care contains a summary list that is accessible to practitioners and contains the following information: a. Any significant medical diagnosis and conditions; b. Any significant operative and invasive procedures; c. Any adverse and allergic drug reactions; d. Any current medication, over-the-counter medications, and herbal preparations. ..."

1. Review of MR23 on August 7, 2017, at approximately 1:00 PM, revealed that the patient was ordered to be transferred to the Emergency Room (ER) on May 3, 2017. There was no documentation that the medical records accompanied the patient to the receiving hospital.

2. Review of MR24 on August 7, 2017, at approximately 1:30 PM, revealed that the patient was ordered to be sent to the ER for evaluation on May 17, 2017. There was no documentation that the medical records accompanied the patient to the receiving hospital.

3. Review of MR31 on August 7, 2017, at approximately 1:45 PM, revealed that the patient was discharged to another acute care facility on March 24, 2017. There was no documentation that the medical records accompanied the patient to the receiving hospital.

4. On August 7, 2017, at approximately 2:00 PM, EMP9 confirmed that there was no documentation in the medical records indicating that the clinical record contents were sent to the receiving facilities for MR23, MR24, and MR31.