Unsigned Provider Orders Due to Incorrect Order Entry
Penalty
Summary
Facility staff failed to ensure that medical provider orders entered into a resident's clinical record by non-prescribing staff were signed or cosigned by the ordering provider. Specifically, several medication and consult orders for a resident with intact cognition were entered by staff as 'Prescriber written' rather than as verbal or telephone orders, which in the facility's electronic record system did not require or allow for provider signature or cosignature. This resulted in the orders for medications such as pantoprazole, famotidine, and insulin, as well as a urology consult, remaining unsigned by the medical provider. Facility policies required that physician orders and progress notes be maintained in accordance with OBRA regulations and that verbal or telephone orders be reviewed and countersigned by the practitioner during their next visit. The Assistant Director of Nursing confirmed that the orders were not signed due to incorrect entry in the electronic record system, which bypassed the requirement for provider signature. The deficiency was identified through interviews, clinical record review, and facility document review.