Observations
Based on the review of client records, the facility failed to document that the prescribing physician signed the verbal orders and/or that the orders were signed within 24 hours in two of four client records.
The findings include:
Ten client records were reviewed on August 11, 2014. Four client records reviewed documented verbal orders. Client records # 2 and 7 documented verbal orders that were not signed by the prescribing physician and/or not signed within 24 hours.
Client # 2 was admitted on May 6, 2014. A verbal order dated May 15, 2014 was signed on May 16, 2014. The physician signing the the order was not the prescribing physician.
Client # 7 was admitted on February 13, 2014. A verbal order dated February 28, 2014 was signed on March 3, 2014. The verbal order was not signed within 24 hours and the physician signing the the order was not the prescribing physician.
The Facility Director and Clinical Supervisor were interviewed on August 12, 2014 and did not dispute the findings.
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Plan of Correction
Only the physician who gave the order will sign the verbal order. These orders will be signed within 24 hours or when the verbal order was submitted. This will be immediate and ongoing. Program Director will monitor for compliance. |