Failure to Transcribe and Implement Physician's Order for Vitamin D3
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and implement a physician's order for Vitamin D3 2000 units daily for a resident who had sustained right ankle fractures. The resident, who had severe osteopenia and was already receiving Os-Cal Calcium plus D3 and a multivitamin, was evaluated by a podiatrist who documented the new order in a progress note. However, this order was not transcribed or implemented as of several days after the evaluation. The failure was identified during a review of the resident's records, which showed that the resident continued to receive less than the prescribed amount of Vitamin D3. The DON confirmed that new orders or progress notes from orthopedic or podiatry appointments were not communicated to the facility and had to be obtained from the electronic health records system. This lack of communication led to the omission of the physician's order for increased Vitamin D3 supplementation.