Failure to Obtain and Implement Physician Orders at Admission
Penalty
Summary
A resident was admitted to the facility from the hospital without any discharge paperwork, including physician orders, medication lists, or care directives. Despite the resident arriving with EMS and reportedly having their paperwork handed to facility staff, the facility was unable to locate or obtain the necessary documentation at the time of admission. As a result, no medications or treatments were administered, and no care plan or directives were initiated for the resident during their stay. The facility's electronic medical record showed no physician orders, no medication or treatment administration records, and no completed pain or nursing assessments for the resident. Nursing staff, including an LPN and RN, documented attempts to obtain the missing paperwork and medication list from the hospital, and notified the DON and the resident's physician, but did not receive a response or any temporary orders. The resident, who had multiple diagnoses including spinal cord abnormalities, chronic pain, heart disease, and a history of myocardial infarction, did not receive any of their prescribed medications, such as blood pressure and pain medications, during their approximately 16-hour stay. The resident was alert and oriented, refused assessments without physician orders, and ultimately decided to leave the facility against medical advice, arranging their own transportation back to the hospital. Interviews with facility leadership and staff confirmed that the facility's policy required physician orders and care directives prior to or at the time of admission, and that the resident should not have been admitted without this documentation. The facility did not provide any skilled care or medications to the resident during their stay, and the necessary hospital discharge summary was not received until after the resident had already left. The deficiency was attributed to the failure to ensure an appropriate admission process, including obtaining and implementing physician orders and care directives for the resident's immediate care.