Failure to Complete Monthly Physician Order Reviews
Penalty
Summary
The facility failed to ensure that physician or advanced practice registered nurse (APRN) orders were reviewed and signed monthly for eleven out of sixteen residents reviewed for physician's orders. Clinical record reviews, interviews, and facility documentation revealed that for these residents, there were multiple months where medical orders were not reviewed or signed as required by the facility's standard practice. The residents involved had various diagnoses, including heart failure, dementia, anxiety, Alzheimer's disease, cerebral palsy, and other chronic conditions. Specific months were identified for each resident where the required monthly review and signature of medical orders did not occur. An interview with the Assistant Director of Nurses (ADNS) confirmed that it was the responsibility of the physician or APRN to review and sign orders monthly, and that this was the facility's standard of practice. However, the ADNS was unable to provide a reason for the missed reviews and signatures. Additionally, the facility could not provide a policy detailing the frequency for reviewing physician's orders, further contributing to the deficiency.