Failure to Ensure Required Physician Visits
Summary
The facility failed to ensure that a resident was seen by their physician as required, which had the potential to delay services and treatment. The deficiency was identified during a review of the records for a resident who was admitted in the winter of 2013 with multiple diagnoses, including dementia, epilepsy, depression, cerebellar ataxia, anxiety, hydrocephalus, and a history of falls. The resident's Brief Interview for Mental Status (BIMS) indicated moderate memory loss. During the review, it was found that physician progress notes (PPN) for January and March 2024 were missing from the facility's electronic health record system. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Physician Assistant (PA), and the Director of Nurses (DON), confirmed the absence of the required physician visits. The facility's policy and procedure stated that the attending physician must visit patients at least once every thirty days for the first ninety days following admission, and then at least every sixty days thereafter. However, the physician did not have PPN in the provider's electronic health record system for the specified months, indicating a lapse in compliance with the facility's policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
Surveyors found that multiple residents with dementia, behavioral disturbances, and schizoaffective disorder did not have required face-to-face physician visits documented over an extended period. Facility policy required the attending physician to evaluate residents at specified 30- and 60-day intervals and document these visits, but record review showed no physician progress notes or H&Ps authored by the physician for several residents. An NP completed assessments and H&Ps, with the physician signing but not dating at least one document, and the DON and ADM reported that the physician rounded weekly and signed NP notes, yet they could not produce any physician-written progress notes or H&Ps for the residents involved.
The facility failed to follow its own policy requiring that initial comprehensive visits be completed by a physician, not by mid-level practitioners. For three residents—one with anxiety, depression, and lung cancer; one with gastroparesis, anemia, and esophagitis with bleeding; and one with emphysema, O2 dependence, and alcohol dependence with withdrawal—clinical record review showed that a CRNP conducted the initial admission or readmission assessments. Late entry notes documented these initial visits by the CRNP, and during interview the DON and interim administrator acknowledged that physician-completed initial visits did not occur as required.
A resident was admitted and remained under facility care until transfer to a hospital, but the attending physician did not complete an initial face-to-face visit, any physical assessments, or the required visits every 30 days for the first 90 days. All documented medical visits and assessments were performed by NPs, and there were no physician progress notes in the record. The DON and Assistant Administrator confirmed that the NP, not the physician, saw the resident. The facility’s physician services policy describes steps when a physician does not make required visits and requires progress notes for physician visits, but it does not define a time frame for the attending physician to assess newly admitted residents.
A resident with vascular dementia, CKD, CHF, A-fib, and diabetes did not have a documented physician visit within the required 60-day interval before a hospital transfer. Record review showed only an NP progress note, with no evidence that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed the resident’s medical management. The DON could not produce documentation of a timely physician visit, and the primary physician reported having neither seen the resident nor having records of NP visits, noting the last physician notes he saw were from another physician many months earlier. This failed to meet federal requirements and facility policy for physician visits and oversight.
A resident with vascular dementia, hemiplegia, cerebral infarction, diabetes, and severe cognitive impairment was not seen by a physician within the required time frames following admission, contrary to facility policy requiring MD visits at least every 30 days for the first 90 days. The initial post‑admission visit was completed by an APNP instead of a physician, and subsequent MD visits were spaced such that a required visit was missed, as confirmed by the NHA through record review and interview.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Ensure Required Physician Face-to-Face Visits and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were seen face-to-face by a physician at the required intervals and that the physician documented these visits in the medical record, as required by facility policy. Surveyors determined that four residents did not have physician progress notes or history and physical (H&P) examinations completed by their physician for a one-year period. Facility policy dated 08/2020 required the attending physician to evaluate residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with documentation of these visits in the health record. One affected resident had dementia with agitation and stimulant-induced anxiety disorder, a BIMS score of 8/15 indicating moderate cognitive impairment, and a care plan addressing cognitive impairment and behavioral issues such as throwing items at others, with interventions including monitoring behavior episodes and documenting potential causes. Another resident had unspecified dementia with behavioral disturbance and a care plan for impaired cognitive function, including using yes/no questions to determine needs. For this resident, an NP completed a history and physical, which was signed but not dated by the physician. A third resident had dementia with anxiety, a BIMS score of 15/15 indicating no cognitive impairment, and a care plan for impaired cognitive function with interventions such as identifying oneself at each interaction and maintaining eye contact. The fourth resident had schizoaffective disorder, bipolar type, with a BIMS score of 15/15 and a care plan for mood problems related to bipolar disorder, insomnia, depression, and anxiety, including risk for mood changes related to pain or discomfort and use of anticonvulsant medications for bipolar disorder. Review of the electronic health records for all four residents showed no physician progress notes, assessments, or H&Ps completed by their physician from 3/27/25 to 3/27/26. During interviews, the DON and ADM stated that the residents’ physician rounded on Wednesdays and signed off on NP notes, but they were unable to provide any written physician progress notes or H&Ps authored by the physician, other than the NP’s H&P for one resident that was signed but undated by the physician.
Failure to Ensure Physician-Completed Initial Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician completed required initial comprehensive visits, as mandated by facility policy and state regulations. The facility’s “Physician Visits and Physician Delegation” policy, dated 6/1/24 and last reviewed 1/21/26, specifies that a PA, NP, or CNS may not perform initial comprehensive visits. Despite this, review of clinical records showed that initial visits for three residents were conducted by a Certified Registered Nurse Practitioner (CRNP), identified as Employee E20, rather than by a physician. For one resident admitted with anxiety, depression, and lung cancer, a late entry note dated 3/1/26 (effective 2/25/26) documented that the CRNP completed the initial admission visit. For another resident with gastroparesis, anemia, and esophagitis with bleeding, who had been discharged home and then readmitted, a late entry note entered on 2/25/26 (effective 2/23/26) showed that the CRNP assessed the resident following readmission, constituting the initial visit. For a third resident admitted with emphysema, oxygen dependence, and alcohol dependence with withdrawal, a late entry note entered on 6/26/26 (effective 6/25/26) documented that the CRNP performed the initial visit. During an interview, the DON and Interim Nursing Home Administrator acknowledged that the facility failed to ensure a physician completed the initial visits for these three residents.
Failure to Ensure Required Attending Physician Visits for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received the required initial face-to-face visit and ongoing visits from the attending physician. The resident was admitted on an unspecified date and remained in the facility until transfer to the hospital on 2/16/26. Record review showed that the attending physician (V10) did not perform an initial visit, did not complete any physical assessments, and did not meet the requirement of one visit every 30 days for the first 90 days of the resident’s stay. All documented medical visits and assessments during this period were completed by nurse practitioners (V8 and V11), rather than by the attending physician. During the survey, the DON (V3) and Assistant Administrator (V2) confirmed that there were no progress notes from the attending physician in the resident’s medical record, and that the nurse practitioner (V11) was the one who saw the resident. The facility’s policy on Physician Services – On Call Coverage states that if a physician does not make required visits, the DON and/or Administrator should be notified, followed by notification of the Medical Director if there is still no response, and that a progress note must be placed in the medical record when a physician visits a resident. However, the policy does not specify a time frame for when newly admitted residents must be physically assessed by the attending physician, and there was no documentation that the attending physician had seen or assessed this resident at any time during the stay.
Failure to Ensure Timely Physician Visits and Oversight of NP Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and the attending physician had face-to-face visits within the federally mandated and facility-required 60-day timeframe. The resident, an older adult with vascular dementia, chronic kidney disease, congestive heart failure, atrial fibrillation, and diabetes, was transferred to the hospital on 9/29/2025 and did not return. Record review showed no documentation of a physician visit for more than 60 days prior to this hospital transfer, and the DON could not provide evidence of a required physician visit when requested on 1/24/2026. The only documentation provided was a nurse practitioner (NP) progress note dated 2/17/2025, with no documentation that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed or directed the resident’s medical care. During interview, the primary physician stated that he had not seen the resident, had no records of his NP seeing the resident, and that the last physician notes he saw in the electronic medical record were from another physician’s services dated 2/17/2024, adding that he would not see a resident who belonged to another physician. The facility’s own policy requires residents to be seen by a physician at least every 60 days with an evaluation of the resident’s condition and total program of care, which the facility was unable to demonstrate occurred within the required timeframes. The facility was therefore unable to show compliance with federal requirements and its own policy for timely physician visits and physician oversight of NP services for this resident.
Failure to Ensure Timely Required Physician Visits After Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and physician met face-to-face at all required visits during the first 90 days after admission, as required by facility policy. The facility’s “Physician Visits and Physician Delegation” policy, revised 7/27/25, states that the physician should see a resident within 30 days of initial admission and that the resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission. Record review for one resident (R6), who was admitted on an unspecified date and had diagnoses including vascular dementia, hemiplegia, cerebral infarction, and diabetes, showed that R6 was not seen by a physician within 30 days of admission (including a 10‑day grace period) and was not seen every 30 days thereafter during the first 90 days. R6’s MDS dated 12/30/25 documented a BIMS score of 6/15, indicating severe cognitive impairment. The initial post‑admission visit was completed by an Advance Practice Nurse Prescriber (APNP) on 2/20/25 rather than by a physician, and subsequent physician visits occurred on 4/8/25 and 6/10/25, leaving a missed physician visit in May 2025. In an interview on 1/20/26, the Nursing Home Administrator confirmed that R6 was not seen by a physician for the initial visit and that a required physician visit was missing in May 2025. These findings show that, for this resident, the facility did not follow its own policy requiring timely, face‑to‑face physician visits within the first 90 days after admission, resulting in missed and delayed physician evaluations documented through staff interview and medical record review.
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