Incomplete Physician Orders for Comfort Care Program
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when the electronic medical record (EMR) did not contain an active physician order for the resident’s Comfort Care Program. The resident was admitted with multiple diagnoses, including heart failure, peripheral vascular disease, cerebral infarction with right-sided weakness, history of falls, and chronic obstructive pulmonary disease. The resident’s Clinical Profile in the EMR listed special instructions for “COMFORT CARE: NO further hospitalization, NO IV fluids, NO discontinuation of medication, NO weights, YES lab work, YES supplements, YES antibiotics.” However, review of the Order Summary in the EMR showed that the Comfort Care order had been discontinued on two separate dates and was not present as an active order at the time of review. During interviews, an LPN described Comfort Care as focused on keeping the resident comfortable and pain free, avoiding invasive or aggressive procedures while still treating conditions such as UTIs. The LPN stated that the unit manager would inform staff when a resident was placed on Comfort Care and that there was supposed to be an active Comfort Care order for this resident, but she was unable to locate it in the EMR. The RN/unit manager confirmed that there should be an active physician order for Comfort Care listed among the resident’s active orders and, upon review of the EMR, verified that no such active order was present. This discrepancy between the Clinical Profile instructions and the absence of an active physician order constituted the identified deficiency.
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