Medications Administered Without Signed Physician Orders
Penalty
Summary
A deficiency was identified when a resident was administered medications without proper physician authorization, as the physician's orders were not signed and dated during a required visit. The resident in question had multiple complex diagnoses, including bipolar disorder, depression, anxiety disorder, unspecified dementia, and other medical conditions requiring a comprehensive medication regimen. The physician's orders included numerous medications and care directives, but the clinical record review revealed that these orders lacked the physician's signature and date at the time of the visit. Interviews with facility staff confirmed that the resident was receiving medications based on unsigned orders. The Regional Director of Clinical Services acknowledged that the physician had not electronically signed off on the orders, and the Registered Nurse confirmed that the orders were being communicated to the pharmacy and considered valid, despite the absence of a signature. The physician later admitted that it was their responsibility to access the electronic system and sign the orders, and confirmed that this had not been done for the resident in question. Facility policy required that medications and biologicals should only be administered upon the order of a physician or prescriber lawfully authorized to prescribe and treat human illness, with orders signed either in writing or electronically. The lack of a physician's signature and date on the orders meant that the medications were administered without proper authorization, constituting a failure to comply with facility policy and regulatory requirements.