F0710

D

Failure to Obtain and Verify Physician Admission Orders for New Admission

Los Angeles, California Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and verify physician admission orders for a newly admitted resident as required by its admission and pharmaceutical services policies. The resident was admitted with diagnoses including diabetes mellitus and hypertension. The admission record showed the resident was admitted from a general acute care hospital with discharge paperwork dated several weeks prior to the admission date. Progress notes documented that the admitting physician’s orders were not entered at the time of admission because the orders needed clarification from the attending physician, and that the hospital’s updated discharge records for the actual admission date could not be located.

Subsequent review of the resident’s record showed telephone orders entered the day after admission listing multiple medications and treatments, including allopurinol, aripiprazole, atorvastatin, carvedilol, famotidine, insulin glargine, regular insulin per sliding scale, latanoprost, levothyroxine, lisinopril, olanzapine, quetiapine, trazodone, and glucagon. An LVN reported that the admitting nurse did not enter physician orders at the time of admission and could not recall why, and that no follow-up call was made to the attending physician because physicians were perceived as not answering facility calls on night shift. The LVN stated that the medication list used for the physician orders entered was taken from the resident’s older hospital discharge paperwork and that these orders were not verified with the attending physician.

Interviews with the attending physician and another physician indicated that neither had given admission orders for the resident on the admission date and that there was no record of admission orders being sent for verification. The attending physician described the usual process of photographing transfer orders and sending them to the physician for review and verbal acceptance or declination, but could not find any evidence this occurred for this resident. Both physicians stated it was important for physicians to review admission orders to prevent medication errors. Review of facility policies confirmed that residents were to be admitted only upon written order of the attending physician and that medication orders must be signed by a licensed physician authorized to prescribe medications. The facility’s failure to follow these procedures resulted in the resident’s admission orders not being verified by a physician.