Failure to Ensure Accurate and Appropriate Physician Orders for Residents
Penalty
Summary
Medical providers at the facility failed to ensure that physician orders addressed the needs of two residents. For one resident, incentive spirometer orders were entered with a delayed start date and without supporting documentation in the clinical record. The orders were signed by a medical provider without adjustment, and both the nurse who entered the orders and the medical director could not confirm for whom the orders were intended. The nurse suggested the orders may have been entered for the wrong resident and could not locate documentation to support their necessity. For another resident, duplicate orders for allopurinol were entered by non-prescribing staff and subsequently signed by a medical provider without identifying the duplication. The duplicate orders remained active until a different medical provider later discontinued one of them after recognizing the duplication. Both residents were assessed as alert and oriented, with adequate cognitive and sensory function documented at the time of the deficiencies.