Failure to Enter Verified Therapy Orders Resulting in Incomplete Medical Record
Penalty
Summary
A deficiency occurred when a verified exercise order for a resident was not entered into the electronic medical record, resulting in an incomplete clinical record. The order, provided by the resident's orthopedic physician, specified passive exercises for the lower extremities and active range of motion for the upper extremities due to the resident's non-weight bearing status. Although the nurse practitioner reviewed and signed off on the order, it was not transcribed into the computer system, and as a result, the ordered therapy services were not initiated. Review of the resident's physician orders for the relevant month confirmed the absence of documentation for the new exercises. The Director of Nursing confirmed that nurse practitioners are responsible for entering their own orders into the system and acknowledged that the resident's medical record did not accurately reflect all current orders. The facility administrator also verified that there was no policy in place for transcribing orders into the electronic system. The affected resident had a history of malignant neoplasm of the cervix, protein-calorie malnutrition, vitamin D deficiency, and bilateral femur fractures, and was cognitively impaired and dependent for transfers, with no ambulation.