Failure to Obtain and Document Physician Orders for COVID-19 Testing
Penalty
Summary
The facility failed to obtain and document physician orders for COVID-19 testing for six residents who exhibited symptoms consistent with COVID-19. In multiple cases, residents presented with symptoms such as fever, cough, malaise, and other respiratory issues, and were tested for COVID-19 without corresponding physician orders or proper documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). For example, one resident tested positive for COVID-19 after exhibiting a fever and cough, but there was no documentation of when the test was performed or by whom, and no physician order was present. Other residents were similarly tested for COVID-19 due to symptoms, but the tests and results were not documented in the appropriate records, and there were no PRN orders for COVID-19 testing in the event of symptoms. Staff interviews confirmed that COVID-19 testing was performed based on the presence of symptoms, but documentation practices were inconsistent, and standing orders for testing had previously lapsed. The lack of physician orders and incomplete documentation for COVID-19 testing did not align with professional standards of practice and placed residents at risk of delayed identification or diagnosis of COVID-19. The deficiency was identified through review of progress notes, MAR/TAR, and staff interviews, which revealed gaps in both ordering and recording of COVID-19 tests for symptomatic residents.