Physician Order Signing Deficiency
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders during their visits for four residents. The facility's policy, titled "Physician Services," mandates that physician orders and progress notes comply with current regulations. However, the clinical records of four residents revealed that their physician orders were not reviewed, signed, and dated as required. Specifically, the last recorded review, signature, and date for three residents occurred on the same date, while one resident's orders had not been reviewed, signed, or dated at all. Interviews with facility staff, including a Registered Nurse Assessment Coordinator and the Director of Nursing (DON), confirmed the oversight. The DON acknowledged that the physician orders for three residents should have been signed every sixty days, but were not signed in the months of September 2024, November 2024, or January 2025. Additionally, the DON confirmed that the orders for the fourth resident should have been signed at admission and every thirty days thereafter for the first ninety days, which did not occur in November 2024, December 2024, or January 2025.
Plan Of Correction
Residents R26, R36, R37, and R42 orders have all been signed/dated by the Elmwood medical staff. Nursing Home Administrator notified the Elmwood medical staff of this noncompliance, and the medical team immediately reviewed, signed, and dated all applicable orders. All other residents' orders have been reviewed by the Elmwood medical staff, and all other residents' orders are in compliance with being signed/dated by the applicable Elmwood medical staff. Physician orders education has been provided to the Elmwood medical staff regarding the requirement of timeliness in reviewing and signing off on resident orders; education was conducted by Nursing Home Administrator. Director of Nursing or designee will conduct whole house audits to ensure compliance with the signing and dating of all orders. Audits will be conducted weekly for 4 weeks, biweekly for 4 weeks, and then monthly for 2 months. Results of these audits will be reviewed at the quarterly quality assurance meeting; any unfavorable auditing results will result in immediate corrective action step(s).