Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for ensuring that physicians review, sign, and date resident orders at admission and on a monthly basis. For five of twelve sampled residents, clinical record review showed that physician orders were not reviewed and signed in accordance with facility practices. One resident admitted on 1/11/26 did not have orders reviewed and signed on 1/14/26 or 2/1/26, another admitted on 1/17/26 lacked signed orders on 1/20/26 and 2/1/26, and a third admitted on 1/18/26 had no evidence of order review and signature on 1/21/26 or 2/1/26. Two additional residents admitted on 2/3/26 and 2/15/26, respectively, did not have their orders reviewed and signed on 2/6/26 and 2/18/26 as expected. During interviews, the DON stated that the admitting physician is responsible for reviewing and signing admission orders when completing the initial history and physical within 48–72 hours of admission and then monthly, and reported being unaware that orders were not consistently signed. The Medical Director similarly stated that the admitting physician is responsible for signing admission orders within 72 hours and monthly thereafter, and explained that when the clinical record is accessed there is no prompt to sign orders, which may have contributed to orders being missed. When requested, the facility was unable to provide a policy specifying the required frequency for physician order review.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.