Physician Order Recapitulation Reports Not Properly Signed and Dated
Summary
The facility failed to ensure that monthly physician order recapitulation reports were properly signed and dated for two patients. For one patient, the Order Summary Reports (OSRs) for two consecutive months did not include the name of the physician who approved the orders, the physician's signature, or the date of approval. During a review with the Director of Nursing (DON), it was confirmed that the monthly recapitulated orders were either unsigned, missing the physician's name, or undated, and the DON acknowledged that the OSRs needed to be signed and dated by the approving physician each month. For the second patient, similar deficiencies were found. The OSRs for two months did not indicate the name of the physician who approved the orders or the date of approval. The DON confirmed during an interview that the monthly physician's recapitulated orders for these months did not include the approving physician's name or the date of approval. Both patients had significant medical conditions, including diabetes mellitus type 2 and cognitive impairments, with one requiring maximum assistance for daily activities and the other being dependent on staff for all care needs. The facility's policy required that monthly recaps be noted by a licensed nurse when the physician signs the recapitulation of orders, but this was not followed in these cases.
Plan Of Correction
Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 10/10/2025, the Director of Nursing (DON) provided an in-service to the Medical Records staff regarding proper completion of the Physician's Order Recapitulation Reports, with emphasis on ensuring all reports are accurately identified, signed, and dated by the physician. - Starting 10/10/25, the Medical Records Director will audit all Physician's Order Recapitulation Reports once a week for 3 months to ensure all reports are accurately identified, signed, and dated by the physician. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The Medical Records Director will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
Penalty
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