Failure to Countersign Verbal Medication Orders
Summary
The facility failed to ensure that verbal orders for medications were countersigned by the prescribing physician within the required 48-hour timeframe, as mandated by state regulations. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy titled "Verbal Orders, Physician Orders and Diagnostic/Lab Results," last reviewed in December 2024, did not include language requiring the physician to sign verbal orders. This oversight was evident in the case of one resident, who had verbal orders for lorazepam and clonazepam entered into their clinical record without the necessary counter-signature from the prescribing physician. The resident in question, identified as Resident 26, had a medical history that included hypertension and bipolar disorder. On December 30, 2024, verbal orders were entered for lorazepam and clonazepam, both of which are schedule IV controlled medications. However, these orders lacked the required counter-signature by the prescribing physician. During a staff interview, the Director of Nursing confirmed that it was the facility's expectation for verbal orders to be signed by the physician as required by state regulation, highlighting a lapse in adherence to this policy.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R26. 2) The Facility reviewed R26, but resident has since discharged and no longer resides at the facility. 3) All current residents were reviewed to ensure that all verbal orders are being countersigned by the physician. Two: system changes and measures that will be taken: 1) All Licensed staff and Physician and Medical Providers will be in-serviced on Physician verbal orders and Physician countersigning orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x week for 4 weeks for compliance with verbal orders then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.
Penalty
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