Observations
Based on the review of patient records, the facility failed to ensure that verbal medication orders were signed by the narcotic treatment physician within 24 hours in two of four patient records.
The findings include:
Twenty patient records were reviewed on January 14-15, 2014. Four patient records included documentation of verbal medication orders. The facility failed to ensure that verbal medication orders included in patient records # 9 and 10 were signed by the prescribing narcotic treatment physician within 24 hours.
Patient # 9 was admitted October 17, 2013. A verbal medication order was documented and signed by nursing staff on December 7, 2013. The narcotic treatment physician did not sign the verbal medication order until December 9, 2013.
Patient # 10 was admitted September 30, 2013. A verbal medication order was documented and signed by nursing staff on November 22, 2013. The narcotic treatment physician did not sign the verbal medication order until November 25, 2013.
The Facility Director and Clinical Supervisor were interviewed on January 15, 2014 and confirmed the findings.
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Plan of Correction
Summit Medical Services' Facility Director will meet with nursing staff as well as the Medical Director on 1/31/14.
Several points will be discussed to ensure proper changes are made: (1) When the Medical Director gives a verbal order, it will be the rule, as per regulations, for the doctor to sign off on the verbal order no more than 24 hours past that point. (2) Because electronic signature is not available and the doctor is not in the facility on Saturday or Sunday, verbal orders cannot be given on Friday after he leaves or Saturday. (3) Times when verbal orders are given will be documented to ensure the doctor signs within the 24 hours.
These above points will be conveyed and discussed in the 2/4/14 staff meeting to ensure all staff (medical, clinical and administrative) are aware of the regulation as well as the procedure of ensuring verbal orders are signed by the medical director within 24 hours of the order being given.
The Facility Director will coordinate the dissemination of this information to all staff. The Medical Director will ensure all signatures are done within the 24 hours after a verbal order. |