Unauthorized Electronic Signing of Physician Orders Using Physician Credentials
Penalty
Summary
The facility failed to ensure that physician orders were properly signed and dated by the responsible physician, specifically Physician R, as required during each visit. Instead, the Medical Records Director was instructed by Administrator O to electronically sign Physician R's orders in the electronic medical record (EMR) system using Physician R's username and password. This practice was carried out for an extended period, with the Medical Records Director logging into the EMR approximately twice a month to sign off on pending orders for Physician R. The Medical Records Director reported that she was initially asked to perform this task after the previous DON left, and that she continued to do so under the direction of Administrator O, despite feeling uncomfortable and recognizing through later training that this was not appropriate. The deficiency was discovered during an audit conducted by the Regional Medical Records Director, which revealed over 100 unsigned physician orders pending in the EMR. Upon investigation, it was found that the Medical Records Director had been using credentials provided by Administrator O to sign these orders, and that this practice had been ongoing for several years. Interviews with staff, including the ADON and MDS Coordinator, confirmed that they were unaware of this practice and that Physician R was not signing his own orders in the EMR. Physician R himself stated that he was not aware his credentials were being used in this manner and that he had been signing paper documents provided to him during his visits, believing these included all necessary orders. The facility's own policies and the Medical Director Agreement required that only the physician sign their own orders, and that usernames and passwords not be shared. The Medical Records Director did not report the inappropriate practice to anyone else, citing fear of job loss, even though an anonymous compliance hotline was available. The improper signing of orders was not detected until the audit, and no evidence was found that the Medical Records Director or Administrator O originated or created new orders, only that they signed off on existing ones entered by nursing staff.