Delay in Stat EEG Due to Unverified Verbal Hold Order
Penalty
Summary
A deficiency occurred when a stat (immediate) EEG order for a resident was not completed as directed by the physician. The resident, who had been admitted with acute respiratory failure, had a stat EEG ordered by a covering physician. The EEG was a contracted service to be performed by an outside technician. Although the technician arrived to perform the test, the house neurologist verbally instructed the technician to hold off on conducting the EEG, despite not being the ordering provider and without a written order to do so. The EEG was subsequently delayed until the following day. Facility policy indicated that non-emergent verbal orders should not be accepted, and emergent verbal orders must be signed by the physician prior to leaving the nursing unit. In this case, the verbal instruction to hold the EEG was not documented as a formal order, and the technician did not consult the ordering provider or inform the assigned nurse about the hold. This sequence of actions and inactions resulted in the stat EEG not being performed as ordered.