Failure to Properly Document and Countersign Physician Telephone Order for Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician telephone order for a fluid restriction was properly documented, signed, and incorporated into the resident’s active physician orders. A resident with diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension was originally admitted and later readmitted with a hospital report indicating a fluid restriction of 750 ml per day. The resident’s MDS showed intact cognition and dependence on staff for ADLs. On readmission, the RN Hospital to RN Facility admission report documented the 750 ml/day fluid restriction, and a Physician’s Telephone Order form dated the same day also indicated a fluid restriction of 750 ml/day due to chronic pulmonary edema. However, the fluid restriction was not entered into the physician’s orders or reflected in the physician order recap covering the admission period. During interviews and record reviews, RN 1 stated he became aware of the fluid restriction from the hospital report but missed inputting the restriction into the physician’s orders. When reviewing the Physician’s Telephone Orders, RN 1 stated he did not transcribe the order and could not identify who did because there was no name or signature on the form. The ADON similarly could not determine who transcribed the telephone order, whether that person was a licensed nurse, or whether the order had been entered into the charting system, and confirmed the fluid restriction was not present in the physician order summary. The Medical Records Director reported that the white copy of the Physician’s Telephone Orders, which should have been returned within five days after the physician’s signature, could not be located, and there was no history of the fluid restriction order in the current or discontinued physician orders. The facility’s P&P required that telephone orders be received only by licensed personnel, reduced to writing with date, time, signature and title of the person transcribing, and countersigned by the physician at the next visit or electronically, which was not followed in this case.
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