Failure to Document Verbal Order for PRN Cough Medication
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for one resident when a nurse did not enter a physician’s verbal order for cough medication into the electronic health record (EHR). The resident was an elderly female with emphysema, lung cancer, end-stage kidney disease requiring dialysis, and diabetes, who had a care plan noting a self-care deficit, a lung tumor, and scheduled dialysis three times weekly. Progress notes documented that the resident had a persistent cough, and on a subsequent day, LVN B documented that cough syrup was administered for this cough. However, review of the resident’s physician orders showed no corresponding order for cough syrup. During interview, LVN B stated she had contacted the resident’s nurse practitioner and received a verbal order for guaifenesin 10 ml every 4 hours as needed for cough, and that she administered the medication immediately due to the severity of the resident’s cough but forgot to enter the verbal order into the physician orders. The DON confirmed that nurses were permitted to accept verbal or phone orders and were expected to write the order down, repeat it back to the prescriber, and enter it into the EMR, ideally immediately or at least before the end of the shift. The facility’s Medication and Treatment Orders policy required that drug orders be recorded on the physician’s order sheet and that verbal orders be recorded immediately in the resident’s chart with the prescriber’s last name, credentials, date, and time. These requirements were not followed in this instance, resulting in an incomplete and inaccurate medical record for the resident.
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