Failure to Transcribe Physician Order and Timely Document Incident in EHR
Penalty
Summary
A deficiency occurred when facility staff failed to properly transcribe a physician's order and ensure timely documentation of an incident in the electronic health record (EHR) for a resident. The incident involved a resident who, during breakfast, accidentally spilled heated tea onto their left arm and abdomen, resulting in redness and blisters. The LPN and CNA present at the time provided immediate care, notified the physician and resident representative, and applied treatment. However, the physician's order for wound care was not entered into the EHR, and the treatment was not signed as administered for two days following the incident. The resident's medical records showed diagnoses including type 2 diabetes mellitus and malignant neoplasm of the breast. Despite the resident having intact cognition and being able to communicate, there was no documented evidence in the progress notes (PN) of the incident on the day it occurred. The LPN entered a late entry note two days after the event, and the initial treatment provided was not documented in the eMAR or eTAR for the relevant dates. The LPN later acknowledged neglecting to enter the physician's order into the computer and confirmed that both the treatment and the incident should have been documented on the day they occurred. Facility policy required prompt initiation and documentation of investigations for accidents or incidents, as well as timely and detailed documentation of procedures and treatments. The DON confirmed that the incident report was not part of the resident's medical record and that the nurse should have documented the event and transcribed the physician's orders in accordance with policy. The failure to document the incident and transcribe the physician's order resulted in a lack of timely and accurate medical recordkeeping for the resident's care.