Failure to Transcribe and Implement Physician Orders for Insulin and Laboratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received treatment and care in accordance with professional standards and physician orders. Facility policy required that all medication and treatment orders be written, dated, signed by an authorized prescriber, and recorded on the physician’s order sheet, with medications administered only upon such written orders. The resident, admitted with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and asthma, had a physician progress note dated 11/28/25 indicating a plan for a repeat urinalysis with culture and sensitivity (UA/CS) and to restart glargine (Lantus) insulin at a lower dose. Review of the medical record from 11/28/25 through 12/23/25, including physician orders, MAR, and nursing notes, showed no documentation of an order for the repeat UA/CS or for Lantus at a lower dose, and no documentation that nursing contacted the physician to clarify these intended orders. A subsequent physician progress note dated 12/23/25 directed administration of low-dose Lantus 6 units every morning subcutaneously. Review of the MAR from 12/23/25 through 12/29/25 (the date of transfer/discharge) revealed no physician orders for Lantus 6 units every morning subcutaneously and no documentation that nursing sought clarification of this order. Interviews with nursing leadership and the physician established that physicians typically enter orders directly into the electronic medical record (PCC), or, if unable, provide verbal orders to nursing for entry. The physician stated he usually enters orders into PCC and must have missed entering the intended orders for this resident, and the DON reported she was unaware of the unacted-upon intended orders documented only in the progress notes. As a result, the intended treatments documented in the physician’s progress notes were not transcribed into active physician orders or implemented.
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