Physician Orders Not Reviewed and Signed at Required Intervals
Penalty
Summary
The facility failed to ensure that physicians reviewed, signed, and dated all orders during each required visit for five out of 25 residents reviewed. According to the facility's policy, physicians are required to see residents every 30 days for the first 90 days after admission and every 60 days thereafter, with all orders to be reviewed and renewed at each scheduled visit. However, clinical record reviews revealed that for several residents with complex medical conditions such as congestive heart failure, COPD, diabetes, hypertension, hyperlipidemia, hypothyroidism, hypotension, and dementia, the last physician review, signature, and date on their orders were overdue and not in compliance with the required schedule. Specifically, the records for these residents showed significant lapses since the last physician review and signature, with some orders not reviewed for several months. During an interview, the DON confirmed that the physician orders for these residents were past due and acknowledged that orders should be reviewed and signed at every required physician visit. The deficiency was cited under relevant state codes for responsibility of the licensee, management, and medical records.