Failure to Ensure Nursing Staff Competency in Obtaining and Documenting Physician Orders
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LPN, possessed and demonstrated the necessary competencies related to obtaining and documenting verbal or telephone physician orders. Review of facility policies, staff competency records, and clinical documentation revealed that a nurse documented new treatment orders for a resident's skin tears without evidence of contacting the resident's physician or obtaining a proper physician order. The nurse's documentation implied that a physician had provided the order, but there was no supporting evidence that such communication occurred. Additionally, the physician later noted that messages were left on an incorrect phone line and that an on-call provider was available, but not contacted. Further review showed that the LPN in question had not received updated education or competency evaluation on obtaining and documenting verbal or telephone physician orders since 2018, despite the facility's assessment identifying this as a necessary competency for staff. The facility's own policy required that verbal or telephone orders be given to and recorded by a licensed nurse, but there was no documentation to confirm that this process was followed in the case of the resident's wound care.