Observations
Based on a review of patient records, the narcotic treatment physician failed to document the proper dosage level for a patient by writing standing orders for the patient's induction phase in three of four patient records reviewed on May 5, 2021.
The following standing order was documented by the physician in patient records # 3, 5 and 7:
"30 mg on the first day, 40 mg on the second day and 50 mg on the third day".
Patient # 3 was admitted October 8, 2020 and discharged February 22, 2021. The standing order was documented on October 8, 2020.
Patient # 5 was admitted November 5, 2020 and discharged March 5, 2021. The standing order was documented on November 5, 2020.
Patient # 7 was admitted November 25, 2020. The standing order was documented on November 25, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Polaris Executive Director has reeducated the Polaris Medical Director on what constitutes a standing order and also in his documentation of initial dose orders, with the initial and induction doses being reviewed specifically. The Medical Director will order the initial dose and document as such in the electronic medical record. Any subsequent dose changes will be based on the medical director's assessment of patient need and ordered one at a time. The nursing staff was also instructed to notify the Executive Director if they see any induction phase orders from the medical director that would be standing orders and to have the medical director properly order and document each dose separately based on daily assessment. The Executive Director will periodically review the induction orders to ensure that they are being ordered and documented appropriately. |