HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that the Nursing staff failed to ensure all patient care assignments were completed as ordered by the physician. This was evident in 1 (Pt. #18) of 20 clinical records completed.

Findings include:

1. Pt. #18 was admitted to the Hospital on 07/20/09 with the diagnoses of sternal wound, shortness of breath, fever and hypertension. The physician ordered daily weights on 07/20/09 and there was no documentation to indicate any weights were obtained.

2. The above findings were verified with the Chief Nursing Officer and Quality manager on 12/10/09 at 10:00 am.

A. Based on a review of Hospital policy, clinical record review and staff interview, it was determined the Hospital staff failed to ensure all verbal orders were timed, dated and authenticated in a timely manner. This was evident in 1 of 20 (Pt.# 16) clinical records reviewed.

Findings include:

1. Hospital policy #PC 3.230 indicates,"All telephone orders must be signed, dated and timed by the physician within 48 hours and verbal orders must be signed, dated and timed by the physician prior to leaving department..."

2. Pt. #16 was admitted to the Hospital on 09/23/09 with the diagnoses of left foot pain, nausea, vomiting and anemia. Verbal orders were written on 09/22/09, 09/23/09 and 09/25/09 for bowel preparation, colonoscopy and medications. There was no documentation to indicate the verbal orders had been dated, timed or authenticated by the physician as of survey date 12/10/09.

3. The above findings were verified with the Chief Nursing Officer and Quality Manager on 12/10/09 at 10:00 am.

B. Based on a review of Hospital policy and procedure, medical record review, and staff interview, it was determined that in 3 of 20 (Pts #6, # 11, and #12) medical records reviewed, the Hospital failed to ensure there were physician orders for all medications/diagnostic tests and that all medications were administered as ordered.

Findings include:

1. The Hospital policy and procedure titled, "Physician's Orders, Transcription Of" was reviewed on 12/10/09. It indicated under, "POLICY 2. ...and verbal orders must be singed, dated and timed by physician prior to leaving department...". And under "OUTCOME: The patient will receive all diagnostic tests, medical treatments, and medications in a timely manner as ordered."

2. The medical record of Pt #6 was reviewed on 12/9/09. It indicated that Pt #6 was admitted on 11/29/09 with a diagnosis of GI Bleed. Documentation indicated that a physician's order, dated 11/19/0 at 8:45 AM was "Give 45 min prior to exam: Atropine 0.4mg IM on call" and "Start IV 1000 D5LR, infuse 300cc of fluid before procedure." There was no documentation that indicated the Atropine or bolus of D5LR was administered as ordered.

3. The medical record of Pt #11 was reviewed on 12/9/09. It indicated Pt #11 was admitted on 12/3/09 with a diagnosis of Chest Pain. Documentation indicated that Pt #11 was administered ASA PO and Nitro sublingual and had the following diagnostic tests: CBC, CMP, and Tronopin. There was no documentation that indicated a physician's order was written for the above.

4. The medical record of Pt #12 was reviewed on 12/9/09 It indicated Pt #12 was admitted on 11/1/09 with a diagnosis of Overdose. Documentation indicated that the following diagnostic tests were performed: CMP, CBC, and Serum Pregnancy. There was no documentation of physician's orders for the tests.

5. During an interview with the Quality Manager, conducted on 12/9/09 at 2:45 PM, the above findings were confirmed.