Failure to Maintain Signed Physician Orders for Held Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and physician orders related to holding medications for three residents. For one resident, the nursing progress note documented that an advanced practice nurse was notified that the resident was a new admission and that medications were not available, and that the practitioner gave an order to hold the unavailable medications. However, a review of the resident’s physician order sheet for that month did not show any signed physician order to hold those medications. For a second resident, nursing progress notes documented receipt of a physician’s order to hold Abilify, Trelegy, and Jardiance until the pharmacy could verify delivery and fill all orders for drop-off that evening, but the corresponding physician order sheet contained no signed physician order to hold these medications. For a third resident, nursing progress notes stated that the resident’s medications were on hold until available, that PRN Ultram and Lasix were obtained from backup, and that the primary care physician was aware that medications were on hold; however, there was no signed physician order in the medical record to support holding the medications. The interim DON confirmed that the electronic medical records for all three residents lacked signed physician orders to hold medications and stated that, per facility standard of practice, telephone or verbal orders must be backed up by a signed physician order and that without such a signature, those orders are insufficient and void.
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