Failure to Document Physician-Ordered Post-Operative Appointment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of three residents reviewed for post-operative care. Specifically, a physician-ordered post-operative appointment was omitted from the resident's medical record, resulting in the resident missing the scheduled appointment. The facility's policy requires that all physician orders be accurately documented and promptly implemented in accordance with CMS regulations and state requirements. However, review of the resident's "After Visit Summary" upon admission showed an order for a post-operative visit, but this order was not entered into the resident's order summary report, and only a later appointment was documented. Interviews with the Director of Nursing (DON) revealed that the admitting nurse, who was responsible for entering all admission orders, failed to document the post-operative appointment. The DON and Assistant Director of Nursing (ADON) also missed the omission during their review of admission orders in the clinical meeting the following day. As a result, the resident, who was admitted with a diagnosis of acquired absence of the left leg below the knee, did not attend the required post-operative orthopedic appointment due to the missed order entry.