Observations
Based on a review of patient records, the facility failed to document the physician determining dosage and all changes in doses in one of four records reviewed.
Patient # 4 was admitted on June 19, 2020 and discharged on November 23, 2021. There was no documentation in the patient chart verifies the physician ordered a denial of dosing on November 17, 2021.
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Plan of Correction
To ensure a change or denial of dosing does not occur when a physician do not order it the following action will be completed. First the regional director shall complete a refresher training with the clinical staff of the facility entitled MMT dosing procedures. The training will cover procedures for dosing, and the procedures for impaired dosing. The training will review the internal system for presenting a case to a MD for a dose review and how any changes if any, will be communicated by the medical personal only. The training will review Soar's policies for medical order changes, how orders are MD driven and how they are the only authorized staff to give or change an order. The training shall be completed within the next 30 days (4/28/22) and copies shall be kept in the HR binder of the clinical staff. Ongoing, if patient is not medicated or subject to a changed by the MD's verbal order, the nursing supervisor shall be notified by email by the close of business that day. The nursing supervisor shall complete an internal audit to ensure a medical note reflecting the MD's decision of a dosing change or denial is present. If a note is not present the MD being notified to complete a review who shall directives for action to the nurse supervisor. Post training any staff who fails to follow the internal policy and systems for dosing changes shall be reviewed and subject to progressive discipline actions. |