Pulmonary Function Tests Performed Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders prior to performing pulmonary function tests (PFTs) on four residents who were reviewed for physician orders. The residents had various diagnoses, including chronic respiratory failure, heart failure, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and dementia. Medical records and care plans for these residents did not contain documentation of physician orders authorizing the PFTs performed on or around the date in question. Interviews with the residents revealed that some did not recall having the tests, while others confirmed the tests had been performed without expressing concerns. Staff interviews indicated that PFTs had been conducted in the past without physician orders, and that an outside company sent a respiratory therapist to the facility to perform these tests. The MDS Coordinator and a Registered Nurse confirmed that the tests were performed on multiple occasions and that there were no physician orders in place. The Director of Nurses acknowledged that physician orders should have been obtained prior to the tests, but could not explain why they were missing from the records. The facility administrator stated that the tests were intended to screen for COPD and that the practice was considered a standard of care according to corporate guidance, but also confirmed that the physician had refused to sign orders for the tests during a recent visit. The respiratory therapist who performed the tests reported being told by the facility that physician orders were in place, but did not see the actual orders. The physician involved did not recall authorizing the tests. The administrator also noted that the facility was under different ownership at the time the tests were performed and that no relevant policy was available for review. No documentation was found to support that physician orders were obtained prior to the administration of PFTs for the residents in question.