Failure to Document Telephone Order for Warm Compress
Penalty
Summary
The deficiency involves the facility’s failure to document a physician’s order for a warm compress in accordance with professional standards and facility policy. A resident was noted on multiple occasions to have swelling of the left lower lip with skin intact, no pain observed, and no tongue swelling or airway compromise. Progress notes dated over several days documented that the physician or on-call physician was notified of the change in condition and that new orders were received to apply a warm compress to the affected area. A subsequent note indicated that the physician was again notified and a new order was received to apply a cold compress, provide routine mouth care, and apply Vaseline to moisten the mouth. On review of the physician orders, surveyors found no evidence that the warm compress order was ever written in the medical record, despite repeated nursing documentation that such an order had been received. The DON confirmed that the warm compress order was not documented for this resident. Facility policy for consulting physician/practitioner orders required that telephone orders be documented on the physician order form with time, date, name and title of the person providing the order, and the signature and title of the person receiving the order, as well as verification by the attending physician and appropriate transcription. An LPN stated that when a change in condition occurs and a telephone order is received, nurses are expected to record the order in the medical record, which did not occur for the warm compress order in this case.
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