Failure to Transcribe and Implement Physician Orders for Compression Therapy and Medication
Penalty
Summary
Facility staff failed to follow physician orders for two residents by not transcribing and implementing orders for compression bandages, ace wraps, and discontinuation of furosemide. One resident was admitted with an order for compression bandages, but this order was not transcribed at admission. The resident’s spouse reported that lower extremity treatments were not being performed as expected. Staff interviews revealed that the initial order for Pro-fore wraps was missed, and when those wraps were used up, staff switched to ace wraps per the physician’s order, but this order was also not properly documented. The physician confirmed that he had ordered ace wraps to be applied daily and had discontinued furosemide, but these orders were not entered into the clinical record. Further review of the clinical record and facility documentation showed that the required process for transcribing and confirming physician orders was not followed. The facility’s policy required that all physician orders, including those from hospital discharge summaries and verbal orders, be transcribed and reviewed by the charge nurse. However, the orders for compression bandages, ace wraps, and discontinuation of furosemide were not entered into the system, and staff interviews indicated confusion about who was responsible for entering these orders. The Director of Nursing confirmed that providers do not enter orders and that it is the responsibility of the nursing staff, but the necessary orders were not transcribed, resulting in a failure to provide care according to physician instructions.