Failure to Obtain and Document Physician Order for Podiatry Appointment
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order for a resident’s podiatry appointment, as required by facility policy and practice. The facility’s Transportation policy stated that social services would assist residents with arranging transportation as needed, and the Documentation in Medical Record policy required that licensed staff and the interdisciplinary team document all services provided in the medical record. The resident in question was cognitively intact, had been admitted and later discharged from the facility, and on the day of discharge walked out of the facility to a bus stop stating she had an appointment and was leaving. A progress note documented that the bus picked up the resident and that the physician was made aware. During closed record review, the resident’s order summary failed to show any physician’s order for the podiatry appointment on that date. RN 2 stated that licensed nurses typically enter appointment orders on behalf of the physician and determine transportation and companion needs, and verified that no such order existed for this resident’s podiatry visit. The Social Services Assistant confirmed that the resident had scheduled a podiatry appointment and acknowledged that a physician’s order was needed for the resident to go to the appointment. The DON also verified there was no physician’s order for the podiatry appointment despite social services knowing about it, and stated there should have been an order so all departments would be aware of the appointment. RN 1 reported that, in usual practice, she would enter the physician’s order for any appointment into the EMR, print it, and provide it to social services, and that physicians usually write such appointments in their orders, but she could not recall being informed of this specific podiatry appointment.
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