Missed Physician Appointment Due to Failure to Transcribe Order
Penalty
Summary
A deficiency occurred when a resident, admitted with a displaced subtrochanteric fracture of the right femur and anxiety, missed a scheduled orthopedic appointment to have stitches removed. The failure was due to the Director of Nursing (DON) not transcribing a telephone order received from the resident's physician into the Treatment Administration Record (TAR) and not communicating the order to the nursing staff. As a result, the resident's appointment for stitch removal was not scheduled, and the resident did not attend the appointment as planned. The error was discovered when the doctor's office contacted the facility about the missed appointment. Upon review, it was found that the admitting nurse also failed to obtain wound care orders during the initial assessment. The DON acknowledged responsibility for not transcribing the order and for the lack of communication, which directly led to the missed appointment. Interviews with facility staff, including the Unit Manager and the prior Administrator, confirmed that the lack of documentation in the TAR and the failure to schedule transportation for the appointment were the primary causes of the deficiency. The resident was later assessed and found to have no signs of infection or harm as a result of the missed appointment.