Failure to Document and Implement Stat Physician Order Received via Text
Penalty
Summary
A deficiency occurred when a physician's order for stat laboratory work, given in response to a family member's concern about a resident's symptoms and medical history of hypokalemia, was not documented, signed, dated, or implemented. The resident's son reported his father was cold, shaky, and not feeling well, and requested lab work to check potassium levels. Although a nurse texted the Advanced Practice Registered Nurse (APRN) with this information and received an order for a stat CBC with differential and a CMP, there was no documentation in the resident's chart of the physician notification, the order, or any lab work being performed on that day. The APRN later confirmed the order was given via text, but could not identify which nurse sent the message, and the order was never carried out. Subsequent review of the resident's medical record revealed no progress notes or documentation of the change in condition or the physician's order on the date in question. The resident later experienced an acute change in condition, including altered mental status and diarrhea, and was emergently transferred to the hospital after a cardiac arrest. The Director of Nursing (DON) confirmed the absence of documentation and implementation of the stat order, noting that the nurse involved was an agency nurse who no longer worked at the facility. The facility did not have a policy or procedure in place for handling medication orders received via text.