Missing Physician Orders for Secured Unit Placement in EMRs
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records by not obtaining or documenting physician orders for placement of residents in a secured unit, as required by facility policy. For three residents reviewed, the EMR lacked physician orders authorizing their admission or continued stay on the secured unit, despite their being housed there. The facility’s own Secured Unit Placement policy required that placement in the secured unit be clinically indicated, based on a comprehensive assessment, and in accordance with physician orders, IDT recommendations, and resident rights, with documentation including a physician order. One resident was an elderly female with dementia, muscle wasting, delusional disorders, heart failure, gait abnormalities, and lack of coordination. Her quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, and no documented wandering behaviors. The census showed she was moved to the secured unit on a specific date, but her physician orders contained no secured unit placement order prior to a later date. Her care plan, however, identified impaired safety awareness and elopement risk related to cognitive impairment, with an intervention that she reside in a locked/secured unit with monitored entry/exit doors. Another resident, an elderly male, was admitted directly to the secured unit with dementia, anxiety disorder, insomnia, hypertension, gait abnormalities, and difficulty walking. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment, and no wandering behaviors in the prior seven days. His physician orders contained no secured unit placement order, while his care plan documented progressive cognitive impairment with risk for injury or elopement and a goal to remain free from injury and elopement. A third resident, an elderly female admitted to the secured unit with dementia, cognitive communication deficit, lack of coordination, and muscle weakness, had an admission MDS showing a BIMS score of 3 and documented wandering on 1–3 days that placed her at significant risk of reaching a dangerous place. Her physician orders also lacked a secured unit placement order, although her care plan documented impaired safety awareness, elopement risk, wandering behavior, and the need for a secured environment. Interviews with the Corporate DON and the MD confirmed that residents were on the secured unit without corresponding physician orders in the EMR, contrary to facility policy.
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