Physician Orders Not Properly Dated or Reviewed
Penalty
Summary
The facility failed to ensure that physicians reviewed residents' total programs of care and that all orders were complete, signed, and dated as required. For one resident, multiple telephone orders over a six-month period were found to be incomplete, with the provider signing but not dating a total of 11 orders. These included medication orders such as loperamide and instructions for administering Resource juice. The Director of Nursing confirmed during record review that these deficiencies existed and that the orders were not properly dated by the provider. For another resident, discharge instructions and provider notes related to conditions such as left hip fracture, hypothyroidism, and diastolic congestive heart failure were signed by the provider but not dated. Additionally, the clinical record did not show evidence that prescribed medications, such as Lasix, were continued in the facility or that required daily weights were monitored. The Unit/Nurse Manager confirmed that the provider's medication list was auto-populated from the provider's office system, which did not always reflect the facility's records, and that the provider did not review the full plan of care or date the signed orders on admission.