Physician Orders Not Reviewed or Signed as Required
Penalty
Summary
The facility failed to ensure that physicians reviewed, signed, and dated all orders during each required visit for five residents. According to facility policy, physicians are required to see residents within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, signing and dating all orders at each visit. However, clinical record reviews for five residents with various diagnoses, including hyperlipidemia, bipolar disorder, traumatic brain injury, hypertension, COPD, and diabetes, showed missing or overdue physician signatures and dates on orders. For some residents, there was no evidence of the last time the physician reviewed, signed, and dated the orders, while for others, the last documented review was several months prior to the survey. During an interview, the Nursing Home Administrator confirmed that physician orders for these residents were past due for review and signature, acknowledging that the facility's practice did not align with its policy or regulatory requirements. The deficiency was cited under relevant state codes for licensee responsibility, management, and medical records.