Failure to Obtain Physician Admission Orders for Resident
Penalty
Summary
The facility failed to ensure that all residents admitted had a written recommendation or written orders from a physician, as required by licensure regulations. Specifically, for one resident who was admitted, the admission orders were written and signed solely by a physician assistant (PA), without a co-signature or involvement from a physician (MD). Review of the resident's medical record confirmed that there was no documentation from a physician recommending nursing home placement or signing the admission orders. Interviews with the Director of Nursing (DON) confirmed that the resident's primary care provider was the PA, and that the resident was not followed by a physician. The DON acknowledged that after reviewing the medical records, there was no evidence of physician involvement in the admission process. The resident in question had multiple complex medical diagnoses, including status post left hip replacement with complications, chronic right hip hardware infection, long-term antibiotic use, hypertension, history of blood clots, anticoagulation, muscle weakness, anxiety, and overactive bladder.