Incomplete Physician Signatures on Verbal Orders
Penalty
Summary
The facility failed to ensure that medical records were complete for one resident, as physician signatures on written telephone/verbal orders were not dated or timed. Record review showed multiple telephone/verbal order slips for a resident with complex medical needs, including cellulitis, peripheral vascular disease, and palliative care, where the physician's signature was present but lacked an associated date and time. These orders included medication changes and new prescriptions, all of which were entered into the electronic medical record (EMR) by the Resident Care Coordinator (RCC), but without individual electronic physician signatures or designated time and date stamps. Interviews with the RCC and the Director of Nursing (DON) confirmed that the process involved physicians signing order slips during weekly visits, but the signatures were not consistently dated or timed. The DON acknowledged that all physician signatures on verbal orders should include a date and time, and clarified that physicians did not enter orders or progress notes directly into the facility's EMR, but rather into a separate hospital-associated EMR. This practice resulted in incomplete medical records for the resident.