Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
The facility failed to ensure that physician orders for all eleven residents reviewed were signed and reviewed monthly in accordance with facility practices. Clinical record reviews showed that for each resident, medical orders were not reviewed or signed for at least one or more months, specifically in May and June. Interviews with the Administrator and a regional RN confirmed that the medical director was responsible for this task, but they were unaware that the orders had not been signed for the specified months. The facility was also unable to provide a policy detailing the required frequency for physician order reviews. Further investigation revealed that the medical director was new to the facility and to long-term care, and had not been informed of the regulatory requirements for signing physician orders. The medical director reported being unable to sign orders electronically due to lack of access in the electronic medical record system, and as of the date of the interview, the issue had not been resolved and the orders remained unsigned. No alternative method for signing the orders had been implemented.