Failure to Transcribe and Implement Physician's Orders for Medication and Lab Work
Penalty
Summary
A deficiency occurred when a physician's order for a resident with schizophrenia, dementia, and anxiety was not properly transcribed and implemented. The resident, who had moderate cognitive impairment and required assistance with daily activities, was evaluated by a psychiatry APRN due to behavioral disturbances, including increased confusion, agitation, and combativeness. The APRN ordered Seroquel 25 mg by mouth every 12 hours as needed for agitation and combative behaviors, as well as laboratory tests including a Depakote level, CBC with diff, CMP, and a urine culture with sensitivity. The written physician's order sheet was marked as 'noted' and initialed by a Registered Nurse Supervisor, indicating that the orders were to be transcribed and followed up on according to facility policy. However, upon review, it was found that only the laboratory work was transcribed into the electronic health record, while the medication order for Seroquel and the urine culture with sensitivity were not entered or acted upon. The laboratory book also showed that a urine sample pick-up was never arranged. Interviews and record reviews confirmed that the required medication and urine specimen orders were not transcribed, despite documentation indicating otherwise. The facility was unable to provide a copy of its Physician's Orders Policy when requested.