Failure to Document Physician Orders and Complete Required Consultations
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice by not documenting a physician's order for a resident to leave the facility on pass and by not following physician's orders for psychiatric and psychological consultations. Specifically, a resident with vascular dementia and a moderately impaired cognitive status was allowed to go outside after the nurse verbally obtained, but did not document, a physician's order for an out on pass. The resident subsequently left the premises, was found by police, and experienced a syncopal episode requiring transfer to the emergency room. Review of the medical record confirmed that no physician's order for the out on pass was documented at the time of the incident. Additionally, the facility did not follow through on physician's orders for psychiatric and psychological consultations for the same resident. Although orders for both consults were present upon admission, the psychiatric consult was not completed until nearly three months later, after the resident's elopement, and there was no evidence that the psychological consult was ever obtained. The DON confirmed that the orders were not followed as written, and the facility's policies required both obtaining and documenting such orders in the medical record.